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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: 84-280——1987年7月8日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,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 level of health benefits provided for physician services under the terms of the 雇主 Benefit Plan.
背景事实
雇员于1986年5月30日从供应商处支付了各种医疗费用. The 雇主 provided benefits for all the charges excluding one fee for diagnostic x-rays and laboratory services. 雇主多次要求提供方提供补充信息 in order to determine if the denied services were medically necessary, but the provider failed to supply the 雇主 with the requested information necessary to administer its 雇主 Benefit Plan. 雇员已要求雇主支付未付的医疗费用.
争端
Is the 雇主 responsible for payment of benefits when the provider has failed to supply documentation to establish the medical necessity of the services?
双方立场
Position of the 员工: The 雇主 is responsible for paying benefits to the provider for medical services rendered to the 员工.
Position of the 雇主: The 雇主 is not responsible for paying benefits to the provider because the provider has failed to supply the 雇主 with the necessary information to satisfy the reasonable and customary guidelines and medical necessity provisions of the 雇主 Benefit Plan.
相关的规定
第三条的导言指出:
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. 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 条病.
条病. A. 《皇冠搏彩中心》第(3)(o)部分规定:
(o) 初级医疗——杂项
2. 为免疫接种提供福利, 过敏脱敏注射, 巴氏涂片, 筛查高血压和糖尿病, 癌症检查, 失明, 耳聋, 以及其他必要的筛查和诊断程序.
3. 如果医生证明有医疗需要，则提供体检津贴. Medically necessary will mean that a Beneficiary (i) has an existing medical condition under treatment by a physician, (ii)年满55岁, (iii) is undergoing an annual or semi-annual routine examination by a gynecologist or (iv) is undergoing a routine examination prescribed by a specialist as part of such specialist’s care of a medical condition.
第三条. A. 《皇冠搏彩中心》第(10)(b)部分规定:
(b) 政府
计划管理人有权颁布实施和管理本计划的规章制度, and such rules and regulations shall be binding upon all persons dealing with the Beneficiaries claiming benefits under this Plan.
第三条. A. (10)(g) 2. 状态:
2. The 雇主 and the UMWA agree that excessive charges and escalating health costs are a joint problem requiring a mutual effort for solution. In any case which a provider attempts to collect excessive charges or charges for services not medically necessary, 如计划所界定, 来自受益人, 计划管理人或其代理人应, 经受益人书面同意, 试着解决这个问题, 通过协商解决方案或为提供商发起的任何法律诉讼进行辩护. Whether the Plan Administrator or his agent negotiates a resolution of a matter or defends a legal action on a Beneficiary’s behalf, 受益人不承担任何法律费用, 定居点, 与案件有关的判决或者其他费用, 但可能对提供商在本计划项下未提供的任何服务负责. 计划管理人或其代理人应全权控制答辩的进行, including the determination of whether the claim should be settled or an adverse determination should be appealed.
第三条. A. 《皇冠搏彩中心》(11)(a)部分规定:
除本计划中另有规定的特定除外事项外, 以下情况也不提供福利:
12. 过多的费用.
讨论
The Plan Administrator and the insurance carrier have applied their previously implemented hold harmless procedures. 费用共115美元.在多次尝试与供应商解决问题后，这些问题仍然存在争议. 这些费用发生在1986年5月30日，是一次办公室访问的一部分，费用为365美元.最初提交了100份. 发票上的诊断包括甲状腺功能障碍, 肌肉骨骼疼痛, 呼吸困难伴胸部不适及更年期综合症. 通常与免疫有关的价值70美元的注射没有医疗必要性. 也不清楚是否盆腔检查和乙状结肠镜检查, 为此要付45美元, 是医学上必需的. 只有在医疗上有必要的情况下，如第三条A款所述，本计划才包括这些检查. (3)(o) 2. 和3. The Plan Administrator requested additional information from the provider concerning charges for the injections, 盆腔检查和乙状结肠镜检查. 5个月后仍未提出正当理由时, 指控被否认为医学上没有必要.
The basic issue in this case is whether sufficient medical information was submitted to the 雇主 to enable the 雇主 to make a medical necessity determination provided for by the Plan. 雇主多次要求提供方提供补充信息, 但提供商未能提交所要求的文档. A Funds’ medical consultant has reviewed the charges as submitted and advises that they are not sufficiently documented to establish their medical necessity.
第三条. defines covered services as those 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, 和第三条. A. (11)(a) 12. 不包括雇主福利计划承保范围内的超额费用. Due to the lack of documentation to support the medical necessity and reasonableness of the medical services and charges in question, 根据雇主福利计划的规定，雇主拒绝支付这些费用是合理的.
受托人的意见
The 雇主 is not responsible for paying the provider for those medical services and charges for which the provider has failed to supply to the 雇主 the information necessary to determine whether the charges are covered under the 雇主 Benefit Plan. 在与提供方存在争议期间，雇主应继续保护雇员不受损害.