受托人的意见
争议的解决
情况下没有. 88-377
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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
88-377 - 1991年4月24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.
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 an 员工’s spouse’s inpatient hospital stay under the terms of the 雇主 Benefit Plan.
背景事实
On December 27, 1989, the 员工’s spouse was hospitalized for a modified radical mastectomy. 雇主预先证明雇员配偶的住院四天. 根据雇员配偶的医生, 由于伤口引流和愈合不良，需要住院治疗第五天. The 雇主 provided benefits for all inpatient charges certified as medically necessary, 但拒绝支付最后一天的食宿费用.
争端
Is the 雇主 required to pay the room and board charge for the last day of the 员工’s spouse’s hospitalization from December 27, 1989年至1月1日, 1990.
双方立场
Position of the 员工: The 雇主 is required to pay the room and board charge because the 员工’s spouse’s physician felt it was necessary for her to remain hospitalized until January 1, 1990.
Position of the 雇主: The 雇主 is not required to pay the room and board charge for the final day of the 员工’s spouse’s hospitalization because the services rendered during that
受托人解决争议意见. 88-377
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经期本可以在门诊的基础上安全、充分地提供, 住院治疗在医学上也没有必要.
相关的规定
雇主福利计划第三条导言规定:
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 患病或受伤，并得到适当的护理, 或计划中另有规定的. 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 they are used repeatedly; procedures which are not ordered by a physician or which are not documented in 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) of the 雇主 Benefit Plan provides in pertinent part: (1) Inpatient Hospital Benefits
(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.
讨论
The Introduction to 第三条 of the 雇主 Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an
受托人解决争议意见. 88-377
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患病或受伤，并得到适当的护理. The Introduction further states that the fact that a 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. 第三条. A. 《官方网站》第(1)(a)款规定，如果受益人由医生入院, benefits will be provided for room accommodations and medically necessary services provided by a hospital for the diagnosis and treatment of the Beneficiary’s condition.
The 雇主 in this case has denied benefits for the room and board charge for the last day of the 员工’s spouse’s hospitalization from December 27, 1989年至1月1日, 1990. A皇冠搏彩中心网站的医疗顾问审查了本案提交的资料, 包括详细的医疗记录和雇员配偶医生的信件. The consultant has advised that the physician’s progress notes do not provide any medical reason for continued hospitalization and the physician’s letters do not provide medical documentation that would justify hospitalization beyond the four days that were precertified. 根据顾问的说法, the nursing progress notes indicate that there was no drainage from the wound on December 28, 1989年12月29日, 1989 the patient was ambulating and taking fluids by mouth; there was no indication of a fever or other signs of infection. 基于这些信息, the consultant concluded that the last day of hospitalization was not medically necessary. 相应的, the Trustees find that the 雇主’s denial of the room and board charge for the last day of the 员工’s spouse’s hospitalization is reasonable under the terms of the 雇主 Benefit Plan.
受托人的意见
The 雇主 is not required to pay the room and board charge for the last day of the 员工’s spouse’s hospitalization from December 27, 1989年至1月1日, 1990.