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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
连杆箱编号.: 88-652 - 1993年9月28日
董事会:Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.
根据集体谈判协议的条款, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for a light box as durable medical equipment under the terms of the Employer Benefit Plan.
背景事实
The Employee’s daughter was diagnosed with recurrent major depressions with a seasonal pattern, 也被称为季节性情感障碍(SAD). The Employee’s daughter’s psychiatrist prescribed a light box in order to perform phototherapy, 使用明亮的人造光的治疗. 他认为明亮的光线(2500到10000勒克斯)有抗抑郁作用. The psychiatrist states that studies in Europe and the United States have shown that treatment with bright environmental light (phototherapy) has been effective in treating SAD.
1992年3月25日，雇员的女儿以490美元的价格购买了灯箱.00 The Employer denied the charges for the light box as not medically appropriate in the treatment of this disease. The Employer notes that light boxes have been approved for the treatment of jaundice or skin disorders, 但在没有医学疾病的情况下，它们并没有被证明是有用的. The Employer states that Seasonal Affective Disorder is not considered a medical illness, 相反，它是一种需要心理治疗而不是治疗性治疗的疾病.
争端
Is the Employer required to provide benefits for the purchase of a light box to treat the Employee’s daughter’s Seasonal Affective Disorder?
各方立场
Position of the Employee: The Employer is required to provide benefits for the purchase of a light box to perform phototherapy on the Employee’s daughter since the light box was prescribed by a physician and has been found to be beneficial in treating SAD.
Position of the Employer: The Employer is not required to provide benefits for the purchase of a light box for the Employee’s daughter since this type of therapy has not been medically proven to be useful in the absence of a medical illness. 因为诊断结果不是医学疾病, 这种情况需要使用心理疗法而不是治疗性治疗.
相关的规定
第三条导言指出:
第三条福利待遇
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 a timely fashion in the patient’s medical records; procedures which can be performed with equal efficacy 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.(6) (d):
(d)医疗设备
提供租金或租金福利, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
第三条.A.(11)(a) 24. 状态:
(11)一般除外条款
(a)除了《皇冠搏彩中心网站》中另有规定的具体除外事项之外, 以下情况也不提供福利:
24. Charges for treatment with new technological devices and therapy which are experimental in nature.
讨论
第三条 provides benefits for 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, 或本计划另有规定. 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 the Plan. The Introduction to 第三条 further states that services which are of unproven value or of questionable current usefulness are not eligible under the Plan.
第三条.A.(6)(d)提供租金优惠, 或者在适当的时候购买, of medical equipment suitable for home use when determined to be medically necessary by a physician.
美国.S. Food and Drug Administration states that the use of a light box in treatment of SAD is not approved for use at this time. Funds staff have contacted several major health insurance carriers concerning their provision of benefits for this type of treatment, 但我没有发现任何能带来好处的方法.
A皇冠搏彩中心网站的医疗顾问审查了本案提交的资料, including a letter from the treating psychiatrist as well as medical literature provided by the light box manufacturer, and has concluded that there is inadequate medical documentation of the patient’s condition, that there is no clinical evidence that treatment with a light box would be more beneficial for the Employee’s daughter’s SAD than more conservative therapy, 光疗法还没有被认为是治疗SAD的有效方法.
第三条.A.(11)(a) 24. excludes benefits for treatment with new technological medical devices and therapy which is experimental in nature. The Trustees conclude that the Employer is not required to provide benefits for the purchase of the light box in the treatment of the Employee’s daughter’s Seasonal Affective Disorder.
受托人的意见
The Employer is not required to provide benefits for the Employee’s daughter’s light box purchased on March 25, 1992.