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受托人的意见
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在再保险

原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 98-016 – 二二年十一月十三日

受托人: A. Frank Dunham, Michael H. 霍兰德，马蒂·D. 哈德逊和 艾略特一. 西格尔.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

The Complainant’s spouse has muscle spasms in her lower back. To help alleviate her muscle spasms, her physician prescribed an RS-4 Neuromuscular Stimulator for use by the Complainant’s spouse at home. The Respondent has denied benefits coverage for the neuromuscular stimulator.

争端

Is the Respondent required to provide benefits coverage for the RS-4 Neuromuscular Stimulator prescribed for the Complainant’s spouse?

Position of the Parties

Position of the 原告: The Respondent is required to provide coverage for the RS-4 Neuromuscular stimulator because the Complainant’s spouse’s physician prescribed the neuromuscular stimulator as part of the Complainant’s spouse’s home therapy.

Position of the 被申请人: The Respondent is not required to provide coverage for the RS-4 Neuromuscular Stimulator because this type of equipment is not medically necessary, and it is not a covered benefit.

相关的规定

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

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, or are otherwise provided for in the Plan. 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. (6) (d) of the 1998 雇主 Benefit Plan provides:

Benefits are provided for rental or, 在适当的地方, purchase of medical equipment suitable for home use when determined to be necessary by a physician.

讨论

The Introduction to 第三条 of the 雇主 Benefit Plan limits covered services to those that are medically necessary for the diagnosis and treatment of an illness or injury. A physician may prescribe services or treatment, but the medical necessity for such care must be established before benefits may be provided under the Plan. 根据第三条. A. (6) (d) of the 雇主 Benefit Plan, benefits are provided for medical equipment.

A Funds’ medical consultant has reviewed the documentation submitted and has concluded that there is inadequate medical justification to approve the neuromusclar stimulator on the basis of medical necessity.
Opinion of the Trustees

The Respondent is not required to provide coverage for the RS-4 Neuromuscular Stimulator prescribed for the Complainant’s spouse.