受托人的意见
争议的解决
情况下没有. 88-595
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OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

员工
雇主
88-595 - 1992年9月21日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. 西格尔,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

On December 31, 1991, the 员工 began to have pain in his shoulder. He attempted to make an appointment with his physician, but was not successful. The next day, January 1, 1992, was a holiday and the 员工’s physician was unavailable. 1月2日, 1992 the 员工 met his physician at a medical center emergency room where that same physician was on duty. The physician injected the patient’s shoulder with Depo-Medrol and placed him on Lodine.

The 雇主 provided benefits for the physician charge, but denied payment for the emergency room charge incurred on January 2, 1992.

争端

Is the 雇主 required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on January 2, 1992?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge incurred on January 2, 1992 because there were acute symptoms that had appeared within 48 hours of the emergency room visit.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on January 2, 1992 because the 员工’s symptoms were not acute and did not require emergency treatment.

受托人的意见 争议的解决 情况下没有. 88-595
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第三条有关规定. A. (2) (a) of the 雇主 Benefit Plan states:

(2)医院门诊福利
(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.

讨论

第三条. A. (2) (a) of the 雇主 Benefit Plan provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.

A Funds’ medical consultant has reviewed the medical records in this case. The consultant notes that the patient was having increasing pain from bursitis in the left shoulder, which was treated with a steroid injection and medication by mouth, thus indicating the severity of the bursitis. 此外, 顾问说, although the medical chart records that the pain had been present for three to four days and was listed as a dull ache at that time, 就像滑囊炎一样, the pain increases over time in a crescendo fashion with the more severe pain having been present for less than 48 hours.

It is the opinion of the consultant that the 员工’s emergency room visit on January 2, 1992 was appropriate because of the increasing pain that was present 48 hours prior to the visit, and the holidays prevented the patient from seeing his physician in the office.

The 雇主 also notes that-he emergency room record classified the case as “non-emergent”. 的资金’ medical consultant has advised in prior cases that the emergency department’s classifications of emergent or non-emergent for coverage review have no relevance. These are classifications used by the hospital staff to determine whether the patient needs care immediately, 几分钟内, 或者可能要等上一个小时或更长时间, if necessary; they are not meant to evaluate the patient’s need for same day emergency care.

The Trustees find that the 雇主 is required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on January 2, 1992.

受托人的意见

The 雇主 is required to provide benefits for the emergency room charges resulting from the 员工’s evaluation and treatment on January 2, 1992.

受托人的意见 争议的解决 情况下没有. 88-595
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