_____________________________________________________________________________
受托人的意见
_____________________________________________________________________________
在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-513——1992年5月7日
Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Elliot A. 西格尔,受托人.
根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, and under the authority of an exemption granted by the United States Department of Labor, 受托人审查了有关根据雇主福利计划条款提供急诊室费用福利的争议的事实和情况.
背景事实
The 员工’s spouse was hospitalized for tests and observation from February 25 to March 2, 1991, following a visit to the emergency room on February 25, 1991 for treatment of acute abdominal pain and nausea. The 雇主 denied benefits for the room and board charges of March 1 and 2, 1991 stating that the last two days of hospitalization were not medically necessary. The 员工’s spouse’s physician submitted a letter dated September 15, 1991年寄给雇主的保险公司，说明雇员的配偶住院到3月2日, 1991 because she has a past history of colon cancer and gangrenous intestine, there was no definite diagnosis for the abdominal pain and nausea, and she was too ill to be discharged. 此外, 医生坚持认为，从医学角度看，有必要进行诊断性检查(结肠镜检查和食管胃十二指肠镜检查)[食管内窥镜检查], stomach and duodenum] on an inpatient basis. After a second review by the carrier, the 员工 was notified on November 11, 1991 that the denial of benefits for the last two days was maintained.
The 雇主 has denied benefits for the room and board charges incurred 3月1日和2日, 1991 on the grounds that the medical necessity of the charges has not been established.
争端
Is the 雇主 required to pay for the room and board charges for the last two days, 3月1日和2日, 1991, of the 员工’s spouse’s hospitalization?
Positions of the Parties
雇员的职位:雇主必须支付最后两天的食宿费用，因为雇员配偶的住院治疗是医疗必要的，属于承保福利. 鉴于其既往病史和症状的性质，住院期间包括观察和检测是必要的.
雇主的立场:雇主不需要支付最后两天的食宿费用，因为没有医疗上的必要性. 2月27日之后, 1991, the 员工’s spouse was eating a regular diet, taking no intravenous medications or fluids and all tests were complete with negative results. 因此, the services performed after February 27, 1991 could have been safely and adequately performed on an outpatient basis.
相关的规定
The Introduction to 第三条 of the 雇主 Benefit Plan provides in pertinent part:
文章III-Benefits
承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内。.
第三条. A. (1) (a) of the 雇主 Benefit Plan states in pertinent part:
A. 健康的好处
(1) Inpatient Hospital Benefits
(a) 半私人的房间
当受益人被持牌医生(以下简称“医生”)作为住院病人在认可医院(以下简称“医院”)接受治疗时。, 补助金将用于半私人房间住宿(包括特殊饮食和一般护理)以及医院为诊断和治疗受益人的病情而提供的下述所有医疗必要服务.
第三条. A. (10)(g) 3. of the 雇主 Benefit Plan states:
(g) Explanation of Benefits (EOB), Cost Containment and Hold Harmless
3. 雇主和妇女协会一致认为，收费过高和保健费用不断上涨是一个共同问题，需要双方共同努力加以解决. 在任何情况下，提供者试图收取过高的费用或对医疗上不必要的服务收取费用, as defined in the Plan, 来自受益人, the Plan Administrator 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 provider. 计划管理人或其代理人是否代表受益人协商事项的解决方案或为法律诉讼进行辩护, the Beneficiary shall not be responsible for any legal fees, 定居点, judgments or other expenses in connection with the case, but may be liable for any services of the provider which are not provided under the Plan. The Plan Administrator or his agent shall have sole control over the conduct of the defense, 包括对索赔是否应和解或对不利裁决是否应上诉的决定.
讨论
雇主福利计划第三条导言规定，所涵盖的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供. 《皇冠搏彩中心》进一步指出，医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不包括在本计划之内. 第三条. A. 《皇冠搏彩中心》第(1)(a)款规定，当受益人作为住院病人被医生收治到医院接受治疗时, 将为半私人房间住宿和为诊断和治疗受益人的病情而提供的所有必要医疗服务提供补贴.
A皇冠搏彩中心网站的医疗顾问审查了这份档案，并指出，所提供的医疗文件表明，病人需要住院观察, pain management and further diagnostic studies. 然而, according to the consultant, 截至2月28日, 1991年，患者不再有需要麻醉注射的疼痛，并且能够口服药物, was ambulatory and could have safely been discharged. 该顾问还指出，腹部CT(计算机轴向断层扫描)和结肠镜检查的诊断研究可以在门诊进行. 因此, 顾问认为，过去两天的住院治疗对于照顾和治疗雇员配偶的病情没有医学上的必要. 相应的, 受托人得出结论，根据雇主福利计划的条款，雇主拒绝支付雇员配偶入院最后两天的食宿费用是合理的.
第三条. A. (10)(g) 3. 《官方网站》规定，计划管理人应尝试与寻求收取非医疗必要服务费用的提供者进行谈判，或保护受益人免受其害. Whether the 雇主 negotiates a resolution or defends a legal action, the Beneficiary is not responsible for any expenses in connection with such charges. This is known as the Plan’s “hold harmless” provision.
在这个例子中, 雇主必须执行符合雇主福利计划规定的保持无害程序.
Opinion of the Trustees
雇主不需要支付上述食宿费，因为雇员配偶的最后两天住院并非医疗需要. The 雇主 is required to initiate hold harmless procedures.