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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 Case No: 93-052 – 1996年10月10日
受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，唐纳德·E. 皮尔斯,小. 和艾略特A. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for diagnostic services under the terms 雇主福利计划的成员.
背景事实
The Employee’s son was referred for evaluation of his condition at the request of his school. A psychiatrist and a pediatrician conducted diagnostic examinations, and both concurred that the Employee’s son had Attention Deficit Disorder (ADD). This has been defined as developmentally inappropriate inattention and impulsivity, 有或没有多动症, 这是一种自我表现的状态, 在某种程度上, 作为一个行为问题. The medications often prescribed for the treatment of ADD can produce severe side effects. 因此, baseline and regular follow-up screening of blood levels are necessary to produce maximum treatment results with minimum side effects.
The Employer has denied benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime as treatment for a school related behavior problem, and thus not subject to benefits under Section III. A. (7) (f) 3. 雇主福利计划的成员.
争端
Is the Employer required to provide benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime?
双方立场
Position of the Employee: The Employer is required to provide benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime because they were medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime because they are part of treatment for school related behavioral problems, which are not subject to benefits under Article III. A. (7) (f) 3. 雇主福利计划的成员.
相关的规定
The Introduction to Article III 有关部分各国:
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, or are otherwise provided for in the Plan. . . .
第三条A. (3) (h)和(j)在相关部分说明:
(h)家庭、诊所和办公室访问
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, 如果由医生提供.
* * *
(j)化验和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.
第三条A. (7) (f) 3. 有关部分各国:
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for: Psychotherapy, 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:
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3. 与学校有关的行为问题.
讨论
The Introduction to Article III 雇主福利计划的成员 limits covered services to those that are medically necessary for the diagnosis and treatment of an 疾病或受伤. 第三条A. (3) (h) provides benefits for physician office visits. 第三条A. (3) (j) provides benefits for laboratory tests when they are ordered by a physician and performed by a licensed laboratory. 第三条A. (7) (f) 3. excludes benefits for treatment of school related behavioral problems.
The Employer has denied benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime as part of the treatment for a school related behavioral problem, 因此被第三条A款排除在外. (7) (f) 3. Although ADD is a condition that can produce behavior aberrations, 包括多动, 在任何时候, it often becomes prominent when a child cannot follow the structured regimen of the classroom. 然而, the onset of ADD is frequently before school age, and ADD is not defined as school-related in standard medical texts such as the American Psychiatric Association’s Diagnostic and Statistical Manual-IV.
Treatment of ADD includes medication that is to be given at regular intervals to obtain optimum results throughout the day. Because of the intensity of the medication, it is necessary to periodically monitor blood chemistry levels to prevent toxicity.
The diagnostic evaluations and laboratory testing were necessary to diagnose accurately the nature of the Employee’s son’s problem as ADD, to rule out other causes and to prescribe appropriate treatment. 因此, consistent with the provisions 雇主福利计划的成员, the Employer is required to provide benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime related to the diagnosis and treatment of the Employee’s son’s ADD.
受托人的意见
Consistent with the provisions 雇主福利计划的成员, the Employer is required to provide benefits for the diagnostic evaluations, 基准实验室测试, and the physician’s visit to begin the medication regime related to the diagnosis and treatment of the Employee’s son’s ADD.