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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: 88-423 – 1992年1月21日

Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
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 benefits for laboratory tests under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse was seen at a family practice office for multiple complaints, 包括髋部疼痛, 食指痛, 体重增加, 阴道分泌物, 喉咙又冷又痛. The physician ordered an ultrasound image of the uterus, x-rays and laboratory tests, including a pathology panel (a series of tests). The 雇主 paid all charges pertaining to this visit, except the charge for the pathology panel.

争端

Is the 雇主 required to provide benefits under the 雇主 Benefit Plan for the pathology panel of laboratory tests?

双方立场

Position of the 员工: The 雇主 is required to pay the charge for the pathology panel of laboratory tests because such tests are covered under the 雇主 Benefit Plan.

Position of the 雇主: The 雇主 is not required to pay the charge for the pathology panel of tests because the tests were non-specific, routine screening that did not diagnose or treat a definite condition, 疾病或受伤.

相关的规定

第三条. A. (3)(j) of the 雇主 Benefit Plan states:

(j) Laboratory Tests and X-rays

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.

讨论

根据第三条. A. (3)(j) of the 雇主’s Plan, benefits are provided for laboratory tests and x-ray services performed in a licensed laboratory when they have been ordered by a physician for diagnosis or treatment of a definite condition, 疾病或受伤. 此外, laboratory tests and x-rays ordered in connection with a routine physical examination are excluded unless considered medically necessary by a physician.

A Funds medical consultant reviewed this file, which includes a detailed record of the patient’s office visit. The consultant notes that the physicians’ current procedural terminology (CPT) code for the pathology panel in question denotes an “executive profile”, which is a comprehensive series of tests usually performed as part of a physical examination. The consultant has advised that the medical notes for the visit in question make no mention of the need for the pathology panel of tests, 它被订购的原因, or the fact that such a panel of tests was ordered or performed. The consultant is of the opinion that the pathology panel in question was not medically necessary for the diagnosis or treatment of a definite condition, 疾病或受伤. 因此, the 雇主 is not required to pay the charges for the pathology panel performed in this case.

受托人的意见

The 雇主 is not required to pay the charge for the pathology panel of laboratory tests performed in this case.