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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 1983年7月25日，81-211
Board of Trustees: Harrison Combs, Chairman; John J. 奥康奈尔,受托人;
Paul R. 迪恩,受托人.
Pursuant to Article IX of the United Mine Workers of America 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 travel expenses for an 员工’s dependent son under the terms of the 雇主’s Benefit Plan and hereby render their opinion on the matter.
背景事实
The 员工’s dependent son has a severe speech impairment and requires speech therapy. 他旅行105英里(往返)。, 每周三次, for speech therapy from a licensed speech pathologist. The 雇主 has paid for the speech therapy, but has denied payment for travel to receive the speech therapy.
争端
Is the 雇主 responsible for payment of travel expenses incurred while traveling to receive therapy?
各方立场
Position of 员工: Is the 员工 responsible to pay for travel costs incurred while traveling to receive speech therapy?
Position of 雇主: Claim is not payable because there are facilities closer and private transportation is available.
相关的规定
第三条. A. (7)(c) of the 雇主’s Benefit Plan provides:
(c) 语言治疗
Benefits are provided for speech therapy rendered by a qualified license speech therapist if the Beneficiary is a stroke patient or has had conditions including ruptured aneurysm, brain tumors or autism and needs special instruction to restore technique of sound and to phonate and needs direction in letter and work exercises in order to express basic needs. Benefits are also provided for speech therapy for child Beneficiaries with a speech impediment from a qualified speech therapist provided that the child cannot receive speech therapy through the public schools.
第三条. A. (7)(e) of the 雇主’s Benefit Plan provides:
(e) 救护车及其他交通工具
Benefits are provided for ambulance transportation to or from a hospital, 诊所, 医疗中心, physician’s office or skilled nursing care facility when considered medically necessary by a physician.
With prior approval from the Plan Administrator, benefits will also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out-of-area 医疗中心.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or 诊所 for such types of treatment as radiation or physical therapy or other special treatment which would otherwise required hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
讨论
根据第三条. A. (7)(e) of the 雇主 Benefit Plan, benefits are provided for transportation when the beneficiary must be taken to an out-of-area medical for needed medical care which is not available near the Beneficiary’s home, when the beneficiary requires frequent transportation between home and hospital or 诊所 for treatment which would otherwise require hospitalization and could not receive the needed care without such transportation, or when the beneficiary requires an escort during transportation that is otherwise a covered benefit. In each case, prior approval of the Plan Administrator is required.
Because the 员工 did not have to travel to an out-of-area 医疗中心 for needed medical care, and although he required frequent transportation, he would not have been required to be hospitalized to receive the care needed without the transportation, he did not meet the requirement for travel. Therefore, the 雇主 is not responsible to pay travel expenses for the 员工’s dependent son.
受托人的意见
The Trustees are of the opinion that the 雇主 is not responsible for payment of travel expenses for the 员工’s dependent son.