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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: CA-038 - 1998年10月1日
受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D.哈德逊和
艾略特一. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Coal Industry Retiree Health Benefit Act of 1992 (Coal Act) 雇主 Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
背景事实
On October 12, 1996, the 养老金领取者 sustained a severe laceration on his thigh from a chain saw. He was seen in the emergency room and had several sutures inserted. He was discharged home with instructions to return on October 14, 1996. The 雇主 provided benefits for each of these visits.
在第二次访问期间, the 养老金领取者’s wound was cleaned and bandaged and he was instructed to return again on October 18, 1996. 下次来访时, he was started on antibiotics and advised to return on October 23, 1996年拆除缝线. The 雇主 denied benefits for the third and fourth visits, saying that they were for care not rendered within 48 hours of an accidental injury and that there were no acute symptoms requiring emergency care.
争端
Is the 雇主 required to provide benefits for the two follow-up visits on October 18, 1996年和10月24日, 1996?
双方立场
Position of the 养老金领取者: The 雇主 is required to provide benefits for the two last follow-up visits because they were medically necessary and because the physician instructed him to return.
Position of the 雇主: The 雇主 is not required to provide benefits for the last two follow-up visits because the 养老金领取者 could have had the service provided at a more appropriate level of care; i.e., he could have visited his family 医生tor for the follow-up care.
相关的规定
第三条A. (2) (a) of the Coal Act 雇主 Benefit Plan states:
(2) 门诊医院福利
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
第三条A. (10) (h) 2. of the Coal Act 雇主 Benefit Plan states, in pertinent part:
(10)总则
(h) Explanation of Benefits (EOB) and Hold Harmless
2. The 雇主 and the UMWA agree that excessive charges and escalating health costs are a joint problem requiring a mutual 解决方案的努力. In any case in which a 提供者 attempts to collect excessive charges or charges for services not medically necessary, as defined in the Plan, from a Beneficiary, the Plan 管理员 or his agent shall, with the written consent of the Beneficiary, attempt to resolve the matter, either by negotiating a resolution or defending any legal action commenced by the 提供者. . .
讨论
根据第三条. A.(2)(a)雇主福利计划, benefits are provided for treatment of an accidental injury when it is rendered within 48 hours following the onset of acute medical symptoms. 第三条. A.(10)(h)2. holds Beneficiaries harmless for care that is not medically necessary.
A Funds’ medical consultant has reviewed the medical records in this case and has concluded that there is no documentation of acute symptoms for the third and fourth emergency room visits and directing the 养老金领取者 to return to the emergency room was not medically appropriate. He further advises that usual emergency room practice requires follow-up visits be done by the patient’s own 医生tor or at a clinic. 在这种情况下, the record shows that the emergency room staff instructed the 养老金领取者 to return for the two follow-up visits.
Since returning to the emergency room for follow-up care was not medically appropriate, the 雇主 is not required to provide hospital benefits for the emergency room charges, but is required to hold the Employee harmless from any attempt by the 提供者 to collect charges for the use of the emergency room for the last two follow-up visits.
受托人的意见
Consistent with the provisions of the Coal Act 雇主 Benefit Plan, the 雇主 is not required to provide benefits for the 养老金领取者’s third and fourth visits to the emergency room, but is required to hold the 养老金领取者 harmless against any attempt by the 提供者 to collect for the charges involved.