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OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: 连杆箱编号:

在再保险

员工
雇主
88-699 - 1993年9月28日

董事会:Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room treatment under the terms of the 雇主 Benefit Plan.

背景事实

周日, 6月28日, 1992, the 员工 sought medical evaluation and treatment for symptoms of a urinary tract infection at the emergency department of a medical center. The emergency room physician diagnosed a urinary tract infection and treated and released the patient.

The 雇主 provided benefits for the physician’s fee, but denied the emergency room charge, stating that care had not been rendered within 48 hours of the onset of acute medical symptoms.

争端

Is the 雇主 required to provide benefits for the emergency room charge associated with the 员工’s medical evaluation and treatment on 6月28日, 1992?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge associated with the 员工’s medical evaluation and treatment on 6月28日, 1992 because the service is a covered benefit.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room charge associated with the 员工’s medical evaluation and treatment on 6月28日, 1992

受托人的意见
连杆箱编号. 88-699
第二页
because there is no evidence in the medical record of acute symptoms requiring emergency treatment.

相关的规定

第三条. A. (2) (a)提供:
(2) Outpatient Hospital Benefits

(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 benefits for emergency medical treatment rendered within 48 hours following the onset of acute medical symptoms. The 雇主 denied the emergency room charge for the 员工’s medical evaluation and treatment for symptoms of urinary tract infection on the basis that the emergency department record indicated that the symptoms had begun three days prior to the visit and had not worsened within 48 hours of the visit, and since care was not sought within 48 hours of the onset of acute medical symptoms, the emergency department charge is not a covered benefit. The 雇主 further stated the emergency department record indicated that the 员工 had previously scheduled a medical appointment with his personal physician and that there is no evidence that the 员工 could not have kept this appointment and been treated at a lower level of care with equal efficiency.

A Funds’ medical consultant has reviewed the records of the emergency room visit and has advised that the 员工 had a past history of urinary tract infections (UTI). The consultant further stated that the record indicated that the symptoms had begun three days prior to the visit and that the symptoms had worsened with increasing frequency and were accompanied by fever. The consultant notes that UTI can become much worse if treatment is delayed for 24 to 48 hours. The consultant is of the opinion that the 员工’s Sunday, 6月28日, 1992 visit to the emergency department was medically appropriate. Because the 员工’s emergency department visit was prompted by acute symptoms that worsened within 48 hours of that visit, and was thus medically appropriate, the Trustees conclude that the 雇主 is required to provide benefits for the emergency room charge resulting from the 员工’s emergency room visit on June 20, 1992.

受托人的意见

受托人的意见
连杆箱编号. 88-699
第3页
The 雇主 is required to provide benefits for the emergency department charge resulting from the 员工’s emergency room visit on 6月28日, 1992.