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OPINION OF TRUSTEES _____________________________________________________________________________
投诉人:被投诉人:ROD案件编号:
在再保险
员工
雇主
84-467——1988年1月11日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人,; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, 并根据美国劳工部授予的豁免授权, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage under the terms of the 雇主 Benefit Plan.
背景事实
雇员的配偶出现关节疼痛, 肌肉痉挛, 头痛, 鼻炎, 失眠和肠胃问题. 根据一位家庭医疗和过敏专家的意见, 人们怀疑食物在她的问题中起了主要作用. 医生认为, 因为她的问题很严重, the 员工s spouse should be hospitalized to test her reactions to foods in a controlled environment. 相应的, in July of 1985 the 员工’s spouse received inpatient care in the ecology unit of a hospital located in Whiteville, 北卡罗莱纳.
The 雇主 denied payment of room and board charges in the hospital on the basis that the inpatient services rendered were not covered. 此外, the 雇主 stated that in 1981 the 员工 and his family underwent tests in a hospital in Texas for the same problem. 虽然计划行政官的意见不包括这笔费用, 当时作了一次例外，支付了旅费和住院费. 随后，该员工收到了日期为1月14日的通知函, 1981 that no further bills for services of that nature would be paid without prior approval from the Plan Administrator.
争端
Is the 雇主 responsible for the payment of charges for the 员工’s spouse’s hospitalization on an ecology unit to test for food allergies?
双方立场
Position of the Complainant: The 雇主 is responsible for the payment of charges for the 员工’s spouse’s hospitalization in an ecology unit to test for food allergies because the test
受托人解决争议意见. 第2页
因为食物过敏在医学上是必要的. 此外, the 雇主 should hold the 员工 harmless from efforts made by the provider to collect its fees.
Position of the Respondent: The 雇主 is not responsible for the payment of charges for the 雇主’s spouse’s hospitalization in an ecology unit to test for food allergies because inpatient hospitalization to test for allergic reactions to foods is not covered under the Plan; such tests can be performed on an outpatient basis. The 雇主 is not responsible for holding the 员工 harmless because he incurred charges for non-covered benefits. 此外, the 雇主 was put on notice by letter in 1981 that such services would not be covered in the future without prior approval from the Plan Administrator.
有关规定第三条的导言指出:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. 在确定合理性和必要性的问题上, due consideration will be given to the customary practices of physicians in the community where the service is provided. 不合理和不必要的服务包括, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when are used repeatedly,; procedures which are not ordered by a physician or which they are used repeatedly; procedures which are not ordered by a physician or which are not documented in a timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. 将继续提供医疗上必要的承保服务, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this 第三条.
第三条. A. (1)(a)部分规定:(a)半私人房间
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.
医院提供的医疗必要服务包括:
受托人解决争议意见. 第3页
手术室、康复室和其他治疗室
化验和x光检查
诊断或治疗项目和服务
药物和药物(包括带回家的药物，限制在30天内
放射治疗
化疗
物理治疗
麻醉服务
氧气及其管理
静脉注射及溶液
血液和血浆的管理
如果不能由受益人或代表受益人代替，则为血液
第三条. A. (11)部分陈述:
(a)除了《皇冠搏彩中心》中另有规定的具体除外事项之外, 以下情况也不提供福利:
16. Inpatient confinements solely for diagnostic evaluations which can be provided on an outpatient basis.
讨论
根据雇主福利计划第三条的条款, covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. A Fund’s medical consultant has advised that the medical information provided does not substantiate that inpatient hospitalization to evaluate suspected food allergies was medically necessary. The Trustees are of the opinion that the 雇主 has correctly denied coverage and has no responsibility to hold the 员工 harmless in this instance.
受托人的意见
The 雇主 is not responsible for coverage of the 员工’s spouse’s inpatient hospitalization charges for tests to evaluate her allergies to food.