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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: 88-592 - 1992年8月26日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. 西格尔,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 influenza vaccinations under the terms of the 雇主 Benefit Plan.
背景事实
12月21日, 1991 the 员工’s spouse sought treatment at her physician’s office due to an upper respiratory infection. During this visit, the 员工’s spouse was administered an influenza vaccination. 雇主为办公室访问提供了福利, but denied benefits for the influenza shot on the grounds that it was not a covered service.
争端
Is the 雇主 required to provide benefits for the influenza vaccination administered to the 员工’s spouse on December 21, 1991?
双方立场
Position of the 员工: The 雇主 is required to provide benefits for the influenza vaccination administered to the 员工’s spouse on December 21, 1991 because immunizations are a covered benefit under the 雇主 Benefit Plan.
Position of the 雇主: The 雇主 is not required to provide benefits for the influenza vaccination administered to the 员工’s spouse on December 21, 1991 because the immunization was not medically necessary.
相关的规定
第三条-福利
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. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, 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 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. Covered services that are medically necessary will continue to be provided, 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. (3)(o) 2. 的“雇主福利计划”规定:
(3) 医生服务和其他初级保健
(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 states that 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 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.
第三条. A. (3)(o) 2. of the 雇主 Benefit Plan provides benefits for many preventive health measures, 包括免疫接种, 还有子宫颈抹片检查, 癌症检查, 失明和耳聋, as well as other screening and diagnostic procedures when medically necessary.
In ROD 88-371 (enclosed herein) the Trustees decided that immunizations administered consistent with standards of medical practice for routine prophylactic vaccinations qualified for benefits under the 雇主 Benefit Plan. ROD 88-371 also notes that medical necessity is not necessarily construed to imply imminent danger or the actual onset of disease or illness, such as the administration of rabies vaccine after a wild animal bite, but also refers to the application of prudent medical practice and preventive care, as in the case of 筛查高血压和糖尿病. This would also include the administration of tetanus, 白喉或麻疹, 腮腺炎和风疹(MMR)疫苗接种.
In this case, the 员工’s spouse was administered an influenza vaccination. Since this vaccination was issued under a physician’s care and is not inconsistent with accepted medical standards and prudent medical practice, the Trustees conclude that the medical necessity requirement of the Introduction to 第三条 and 第三条. A. (3)(o) 2. 是遇到了, 因此, the influenza vaccination is eligible under the terms of the 雇主 Benefit Plan.
受托人的意见
The 雇主 is required to provide benefits for the influenza vaccination administered to the 员工’s spouse on December 21, 1991.