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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: 88-223——1990年1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 health benefits for psychological evaluation and therapy under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s attorney suggested that the 员工 obtain a psychological evaluation on a voluntary basis from a clinical psychologist to be used as part of the 员工’s defense against a criminal prosecution. 该员工于7月6日接受了临床心理学家的评估, 并于9月16日和30日接受了个人心理治疗, 1989年和10月4日, 14和21, 1989. The 雇主’s insurance carrier notified the 员工 in a letter dated September 27, 1989 that it was denying benefits for the psychological evaluation and individual psychotherapy sessions because the evaluation was neither medically necessary nor ordered by a physician. The 员工’s physician wrote a letter to the clinical psychologist dated October 16, 1989, 转介雇员接受"医疗照顾和治疗".”
争端
Is the 雇主 required to provide benefits for the 员工’s psychological evaluation and individual psychotherapy sessions?
双方立场
Position of the 员工: The 雇主 is required to provide health benefits for the 员工’s psychological evaluation and individual psychotherapy sessions.
Position of the 雇主: The 雇主 is not required to provide health benefits for the 员工s’s psychological evaluation and individual psychotherapy sessions because the evaluation was neither medically necessary nor ordered by a physician.
相关的规定
雇主福利计划第三条导言中规定:
文章III-BENEFITS
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 第三条.
第三条. A. 雇主福利计划第(7)(f)条规定:
(7) 其他好处
(f)门诊心理健康、酗酒和吸毒
福利包括:
心理治疗, 心理测试, 咨询, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically required by a physician.
不提供下列福利:
1. 相遇和自我完善的团体治疗.
2. 与智力迟钝和其他智力缺陷有关的监禁.
3. 与学校有关的行为问题.
4. 私人教师服务.
5. Alcoholism and drug rehabilitation if an advance determination has not been made by the rehabilitation team that the Beneficiary is a good candidate for rehabilitation.
6. 不被医疗保险批准的酗酒和戒毒项目.
讨论
根据雇主福利计划第三条的介绍, 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. 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. The Introduction further states that services that are not reasonable and necessary shall include procedures which are not ordered by a physician. 根据第三条. A. (7) (f)计划, 为心理治疗提供福利, 心理测试, 咨询, group therapy and alcoholism or drug rehabilitative programs when free care sources are not available and when determined to be medically required by a physician.
在这种情况下, the 员工’s attorney recommended that the 员工 obtain a voluntary psychological evaluation from a clinical psychologist. 评估是在7月6日进行的, 1989, and the 员工 began seeing the clinical psychologist for individual psychotherapy sessions on September 16, 1989. After the 雇主 denied benefits for the services on the basis that they were not ordered by a physician, the 员工’s physician wrote a letter to the clinical psychologist referring the 员工 for medical care and treatment. 然而, the letter does not specify the type of treatment for which the 员工 was being referred or why such treatment was medically necessary. Because the medical necessity of the 心理测试 and psychotherapy rendered in this case has not been established, 按照第三条的要求. A. (7)(f), the 雇主 is not required to provide benefits for those services.
受托人的意见
The 雇主 is not required to provide health benefits for the 员工’s psychological evaluation and individual psychotherapy sessions in this instance.