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受托人的意见
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在再保险

原告: 退休人员
被申请人: 雇主
ROD案例编号: 81-337——1983年11月28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 review the facts and circumstances of this dispute concerning the level of health benefits for pediatric services and hereby render their opinion on the matter,

背景事实

The Complainant is a disability pensioner eligible for health benefits under the 雇主’s Benefit Plan. 3月18日, 1983, he underwent corrective foot 手术 in his pediatrist’s office to correct a painful hammer toe on his right foot and for the removal of painful exostosis and the release of tendon contractures on his left foot, The 雇主 has denied payment for the charges relative to the 手术,

争议问题

Is the 雇主 responsible for payment of the charges incurred by the 退休人员 as a result of his outpatient podiatric, 手术?

各方立场

Complainant’s Position: The 雇主 is responsible for payment of the charges for the 手术 performed in the podiatrist’s office.

雇主’s Position: The 雇主 is not responsible for payment of the charges because the Plan requires (1) major 手术 to be performed in a hospital and (2) prior approval of the Plan Administrator. The 雇主 contends that neither of these conditions were satisfied in this case.

相关的规定

o第三条A款. (3) (n)规定:

PRIMARY CARE – PODIATRISTS’ SERVICES

Benefits are provided for minor 手术 rendered by a qualified licensed podiatrist. Routine care of the feet such as trimming of nails, 玉米的处理, bunions (except capsular or bone 手术 therefor) and calluses is excluded.

Covered minor 手术 includes 手术 for ingrown nails and 手术 in connection with the treatment of flat feet, 堕落的拱门, 弱的脚, chronic foot strain or symptomatic complaints of the feet.

Benefits for major surgical procedures rendered by a licensee podiatrist are not provided, except if such 手术 is rendered in a hospital.

讨论

根据第三条A款. (3)(n) of the 雇主’s Benefits Plan, benefits are provided for minor 手术 rendered by a qualified licensed podiatrist. There is no requirement that minor 手术 be performed in a hospital or receive prior approval of the Plan Administrator.

This disabled miner underwent 手术 to correct a painful hammer toe on his right foot and for the removal of a painful exostosis and the release of tendon contractures on his left foot. This 手术 was performed on an outpatient basis by a podiatrist in his office. None of the surgical procedures performed is difficult or hazardous. These procedures were performed as surgical management for basically minor problems.

The 雇主’s rationale for denying this claim is that these procedures constitute major 手术. 的资金’ medical staff and physician consultant have reviewed this case and have determined that this 手术 is generally considered minor 手术 which can be safely and effectively performed by a podiatrist in an outpatient setting.

Because these procedures constitute minor 手术 and were performed by a qualified licensed podiatrist for the treatment of symptomatic non-routine complaints of the feet, the Plan provisions regarding podiatry services, 已经满意了.

受托人的意见

The Trustees are of the opinion that the 雇主 is responsible for providing benefits for podiatric 手术 performed on the Pensioner on March 18, 1983.