受托人的意见
争议的解决
情况下没有. 84-686
第1页 _____________________________________________________________________________

对受托人的看法 _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
84-686 - 1989年3月22日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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, 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 for inpatient hospitalization under the terms of the 雇主 Benefit Plan.

背景事实

雇员的配偶在精神病院住院35天, 7月18日起, 1986年至8月22日, 1986. 出院摘要上说她的入院诊断是重度抑郁症, 单集. 9月16日, 1986, the attending psychiatrist stated that the 员工’s spouse developed severe bronchitis and a pneumonia-like illness and was bedridden for the last several days of her stay. 在此期间，她接受了内科医生的抗生素治疗, 她的心理治疗和精神药物治疗也被暂停. The 员工’s spouse recovered from this illness and was to resume her psychiatric treatment when she demanded to be discharged, 她违背了心理医生的医嘱. The attending psychiatrist later stated that the 员工’s spouse had not achieved the maximum benefit from her hospitalization at the 30-day point of her stay, 急性医疗并发症需要继续住院治疗.

The 雇主 provided coverage for the first thirty (30) days of the 员工’s spouse’s hospitalization in a psychiatric facility, 但它拒绝为她停留的最后5天提供保险.

争端

Is the 雇主 required to provide benefits for the 员工’s spouse’s hospitalization in a psychiatric facility for more than 30 days?

双方立场

受托人解决争议意见. 84-686
第二页

Position of the 员工: The 雇主 is required to provide benefits for the 员工’s spouse’s hospitalization in a psychiatric facility for more than 30 days because extended hospitalization was deemed medically necessary by the patient’s 医生tor.
Position of the 雇主: The 雇主 is not required to provide benefits for the 员工’s spouse’s hospitalization in a psychiatric facility for more than 30 days because continued treatment on an inpatient basis was not medically necessary for the treatment of her mental illness or medical complications.

相关的规定
《皇冠搏彩中心网站》第三条导言中有关部分规定:

第三条-福利

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.

第三条. A. 雇主福利计划(1)(e)规定:(1)住院病人福利

(e)精神病

Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. 当医疗需要时, 住院时间可以延长 for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, 每一次急性疾病. (2年内因精神疾病被监禁90天以上, (从住院第一天算起, even if the first day of confinement occurred during a prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide inpatient hospital benefits).

讨论

The Introduction to 第三条 of the 雇主 Benefit Plan states that covered services are 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. The Introduction further states that 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 the Plan.

受托人解决争议意见. 84-686
第3页

第三条. A. (1)(e) of the Plan states that benefits are provided for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist for up to a maximum of 30 days. 它进一步指出, 当医疗需要时, hospitalization for an acute (short-term) mental illness may be extended for a maximum of 30 additional days 每一次急性疾病.

雇员的配偶在精神病院住院35天. The 雇主 paid the charges for the first 30 days of treatment but denied payment for the remainder of the hospitalization as not medically necessary.

The 员工’s spouse contends that an extended period of hospitalization was medically necessary due to her medical condition and/or to an acute episode of mental illness. 第三条. A. (1)(e)仅在急性精神疾病的医学需要时才述明, 住院时间可以延长. 第三条. A. (1)(e) does not state that hospitalization for mental illness may be extended 当医疗需要时 due to any other illness. It is not necessary to decide that issue in this case because the 员工’s spouse’s physical illness did not necessitate hospitalization. 雇员的配偶在住院的最后几天感到虚弱和恶心. 她的主治精神病医生就这些症状咨询了一位内科医生. The discharge summary indicates that the internist diagnosed her condition as rhinopharyngitis (inflammation of the mucous membrane of the nose) and thrombocytopenia (abnormal decrease in the number of blood platelets). 她接受了保守治疗. A Funds’ medical consultant reviewed the file and advised that the 员工’s spouse’s condition did not require extended hospitalization.

The evidence also does not establish that extended hospitalization was necessary due to the 员工’s spouse’s mental illness. 入院诊断为重度抑郁症，单次发作. 在她住院的最后几天，她的精神治疗极为有限. 主治精神病医生没有说延长住院治疗是由于精神疾病的医学需要. 他只说，雇员的配偶在住院30天后没有达到"最高住院津贴". A Funds’ medical consultant has reviewed the file and determined that the 员工’s spouse’s mental illness did not necessitate extended hospitalization. 咨询师建议，可以在门诊的基础上提供持续的精神治疗.

受托人的意见

The 雇主 is not required to provide benefits for more than 30 days of the 员工’s spouse’s hospitalization for acute mental illness, 也不为住院治疗5天的医学症状，不需要住院治疗.