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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: 88-349 - 1991年5月8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 coverage for a cholesterol screening test under the terms of the 雇主 Benefit Plan.

背景事实

On April 16, 1990, the 员工 was seen by a physician for concerns about a mole and knee problem. The physician recommended that the 44-year-old 员工 undergo a cholesterol screening test as it was her first visit to the office and she had never had her cholesterol level measured before. The 员工 contends that the test was medically necessary because she has a family history of cholesterol problems. According to a statement from the 员工’s physician dated November 12, 1990, the physician ordered the test because recent literature and government reports indicate that every adult should be screened for elevated cholesterol. The physician also stated that the 员工’s cholesterol level was elevated and she is now on a cholesterol-lowering diet.

The 雇主 denied benefits for the cholesterol screening test performed on the 员工.

争端

Is the 雇主 required to provide benefits for the cholesterol screening test performed on the 员工 on April 16, 1990?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the cholesterol screening test because the test was ordered by the 员工’s physician and was medically necessary given her family history of cholesterol problems.

Position of the 雇主: The 雇主 is not required to provide benefits for the cholesterol screening test because it was not performed to diagnose or treat a definite condition, 疾病或受伤 and therefore it is not a covered benefit under the 雇主 Benefit Plan.

相关的规定

The Introduction to 第三条 of the 雇主 Benefit Plan provides in pertinent part:

Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an 疾病或受伤 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.

第三条. A. (3)(j)和(3)(o) 2. 的“雇主福利计划”规定:

(3) Physicians’ Services and Other Primary Care

(j) 化验及x光

Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, 疾病或受伤.

Such benefits will not cover laboratory tests and x-rays ordered in connection with a routine physical examination, unless the examination is considered medically necessary by a physician.

(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, and other screening and diagnostic procedures when medically necessary.

讨论

The Introduction to 第三条 of the 雇主 Benefit Plan limits covered services to those which are reasonable and necessary for the diagnosis or treatment of an 疾病或受伤 and which are given at the appropriate level of care, 或计划另有规定. The Introduction further states that 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. 根据第三条. A. (3)(j)计划, benefits are provided for laboratory tests and x-rays when ordered by a physician for diagnosis or treatment of a definite condition, 疾病或受伤. 根据第三条. A. (3)(o)2. 计划的详情, 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, and other screening and diagnostic procedures when medically necessary.

In this case, the 员工 sought medical evaluation and treatment for a mole and a knee problem. The physician has stated that he ordered a cholesterol test in connection with his examination of the 员工 because recent literature and government reports indicate that every adult should be screened for elevated cholesterol. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that the cholesterol test performed in this case was a screening examination that was not medically indicated for the 员工’s complaints. Because the medical necessity of the test performed in this case has not been established, the 雇主 is not required to provide benefits for it under the terms of the 雇主 Benefit Plan.

受托人的意见

The 雇主 is not required to provide benefits for the cholesterol screening test performed on the 员工 on April 16, 1990.