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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 Case No: CA-002 – 一九九九年三月二十三日
受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D. 哈德逊,
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 hearing aids under the terms of the Coal Industry Retiree Health Benefit Act (Coal Act) 雇主 Benefit Plan.
背景事实
On June 14, 1993, the 养老金领取者 underwent a series of hearing aid tests costing $205.00 in order to be fitted for binaural hearing aids. The hearing aids were dispensed the same day at a cost of $2,995.00. 全部账单总计3200美元.00. The 养老金领取者, who lives in Pennsylvania, went to a 德州 hearing aid vendor.
雇主否认了所有指控, stating that the vendor was not a participating vendor under the terms of 第三条.A.(7)(d) of the 1988 雇主 Benefit Plan. The 养老金领取者 qualifies as a Coal Act retiree. The terms of applicable provisions of the Coal Act 雇主 Benefit Plan are identical to the 1988 雇主 Benefit Plan, 这个案子就是根据这个案子提起的.
争端
Is the 雇主 required to provide benefits for the hearing testing and binaural hearing aids purchase by the 养老金领取者 on June 14, 1993?
双方立场
Position of the 养老金领取者: The 雇主 is required to provide benefits for the 养老金领取者’s hearing testing and hearing aid purchase as required by the 雇主 Benefit Plan. The 养老金领取者 states that the non-participating out-of-area provider was used because this was the only vendor available qualified to handle the type of hearing aid needed by the 养老金领取者. 另外, the 养老金领取者 states that the 雇主 is obligated to pay for the expenses under an “exception provider” basis.
Position of the 雇主: The 雇主 is not required to provide benefits for the 养老金领取者’s hearing aid purchase since 第三条.A.(7)(d) requires that any hearing aid purchase be made from a participating provider, and the 养老金领取者’s purchase was 来自非参与供应商.
相关的规定
第三条.A.(3)(o)2. of the Coal Act 雇主 Benefit Plan states:
(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 necessary.
第三条.A.(7)(d) of the Coal Act 雇主 Benefit Plan states in pertinent part:
(7) 其他好处
(d) 助听器
Benefits are provided for hearing aids recommended by a licensed otologist or otolaryngologist and a certified clinical audiologist. Such hearing aids must be purchased from a participating vendor. . . .
讨论
第三条.A.(3)(o)2. of the Coal Act 雇主 Benefit Plan provides benefits for certain examinations for hearing. 第三条.A.(7)(d) of the Coal Act 雇主 Benefit Plan provides benefits for hearing aids when recommended by a licensed otologist, otolaryngologist and a certified audiologist and when purchased from a participating vendor.
The 养老金领取者 has stated that he checked the participating provider list of the Funds’ Johnstown field service office and found no provider in the area who sold this particular type of hearing aid. 然后，领取养老金的人去了沃斯堡, 德州, 他女儿住的地方, 给非参与的提供者, to obtain the hearing aids he states could not be obtained in the area where he lived. The 养老金领取者 has not submitted any medical evidence supporting the need for a unique hearing aid, or indeed that this type of hearing aid is itself unique.
Funds staff has determined that at the time of the 养老金领取者’s purchase of the hearing aids the vendor was not a participating provider under the Funds’ plan, whose participating provider list is also used by the 雇主. The Trustees conclude that the 雇主 is not required to provide benefits for the hearing aids purchased by the 养老金领取者 on June 14, 1993. 然而, the Coal Act 雇主 Benefit Plan does not state that hearing examinations must be conducted by participating vendors. 因此, the 雇主 is required to provide health benefits for the 养老金领取者’s auditory examination on June 14, 1993年共205美元.00. Since the 雇主’s claims administrator’s Explanation of Benefits indicates the 养老金领取者 has 医疗保险 Part B coverage, the hearing testing would only be considered for benefits after 医疗保险 has paid its portion, and a 医疗保险 Explanation of Benefits is provided to the 雇主 for coordination of benefits purposes.
The 养老金领取者 states that benefits for the binaural hearing aids should be provided under an “exception provider” basis. The Coal Act 雇主 Benefit Plan contains no such provision.
受托人的意见
Consistent with the provisions of the Coal Act 雇主 Benefit Plan, the 雇主 is required to provide benefits supplemental to 医疗保险 for the 养老金领取者’s auditory examination on June 14, 1993, but is not required to provide benefits for the hearing aids purchased on June 14, 1993, 来自非参与供应商.