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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: 1981年1月27日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; 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 prescription drug benefits and hereby render their opinion on the matter.

背景事实

The Complainant is an active mineworker eligible for health benefits under the 雇主’s Plan. The Insurance Carrier has denied the payment of claims submitted by the 员工 for a supply of Similac PM 60/40. Similac is an infant formula which can be fed to those infants whose renal, 消化, and/or cardiovascular functions would benefit from lowered mineral and protein levels, 在人乳中发现的. This is not a legend drug for which a prescription is required. The 员工 states that the supply of infant formula was prescribed by a urologist who performed surgery on the 员工’s baby for treatment of a chronic kidney disorder.

争端

Is the 雇主 responsible for the payment of claims for a supply of infant formula?

各方立场

Position of Claimant: The 员工 feels that since he was given a written prescription for the infant formula by the urologist, he should be able to receive credit towards his prescription deductible. The prescription is for a special infant formula necessary to treat kidney disorders.

Position of 雇主: The 雇主 has not responded to the Funds’ three requests for a statement on his position.

相关的规定

• 第三条, A(4)(a) of the 雇主’s Plan provides benefits for insulin and prescription drugs prescribed by a physician for treatment or control of an illness or a non-occupational accident.

• 1978 合同问uestion and Answer #34, approved by the Trustees on May 24, 1978 provides as follows:

主题: Definition of Prescription Drug Benefit

References: 雇主’s Plan, 第三条, Section A(4)(a) and (b).

Question: What is covered under the prescription drug benefit?

答: 的资金 will pay for 药物治疗 prescribed by a physician for treatment or control of a chronic (long term) illness or injury as listed on the Funds’ Basic Drug List which was in effect on December 5, 1977.

For acute (short-term) illnesses or injuries, the Funds will pay for 药物治疗 which, 根据联邦法律或法规, can be dispensed only with a prescription. For acute illnesses or injuries, the benefit does not include drugs, 药物治疗, or supplies that may be obtained over the counter (OTC) without a prescription. Examples of items not covered for the treatment of acute illnesses or injuries are: bicarbonate of soda, 制酸剂(e.g., Maalox), aspirin, and many cough or cold preparations. Even though some birth control drugs require a prescription they are not a covered benefit regardless of the purpose for which they are prescribed. Because some state laws or regulations may differ, the Federal Laws and regulations will prevail in the interest of maintaining uniformity of benefits from one state to another.

All prescriptions must state the diagnosis.

讨论

根据第三条, Section(4) of the 雇主’s Plan, benefits are provided for drugs prescribed by a physician for the treatment or control of an illness or a non-occupational accident. 合同问&A #34 further clarifies that benefits are provided for drugs for the treatment of a chronic illness only when prescribed by a physician and when the 药物治疗 is listed on the Funds’ Basic Drug List. 在这种情况下, although the Similac 60/40 PM may have been prescribed by a physician, this infant formula does not require a prescription, nor is it listed on the Funds’ Basic Drug List. Therefore, this formula is not a 药物治疗 for which benefits are provided.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for payment of charges for a supply of infant formula.