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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: CA-055 - 2005年9月13日
受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰,
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 Coal Industry Retiree Benefit Act of 1992 (Coal Act) 雇主 Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
背景事实
在医生的体检之后, the Complainant has been diagnosed with Peyronie’s disease (curvature of the penis during erection). 在佩罗尼氏病中, fibrous tissue develops within the penis and obstructs the vascular pathway that runs its length. The Complainant underwent surgery for the release of Peyronie’s disease at the base of his penis, 这能让弯曲的阴茎变直. 除了, the Complainant’s physician has prescribed Viagra which the physician states helps the Complainant to maintain a straighter erection. 被告拒绝了伟哥的保险.
争端
被告是否需要为处方药伟哥提供保险?
双方立场
Position of the 原告: The Respondent is required to provide coverage for Viagra because the Complianant’s physician prescribed the drug for the Complainant to maintain a straighter erection.
Position of the 被申请人: The Respondent is not required to provide coverage for Viagra because medications to treat sexual dysfunction are considered lifestyle drugs and have traditionally not been covered by the benefit plan. 另外, 答辩人不应因个人事务(例如性关系)而招致任何费用.
相关的规定
《皇冠搏彩中心》雇主福利计划第三条导言指出:
第三条-福利
Subject to Article IV, the benefits provided under this Plan are set forth in this 第三条. Benefit payments shall not exceed reasonable and customary charges for covered services and supplies. 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 timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. The benefits described in this Article are subject to any requirements implemented pursuant to Article IV. 将继续提供医疗上必要的承保服务, 和相应的, 虽然福利金支付可能受到管理式护理和成本控制规则的约束, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this 第三条.
第三条. A. 《皇冠搏彩中心》(4)(a)相关部分规定:
(4) 处方药
(a) 提供的福利
Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or a nonoccupational accident or (ii) licensed dentist for treatment following the performance of those oral surgical services set forth in (3)(e). . . .
讨论
The Introduction to 第三条 of the 雇主 Benefit Plan limits covered services to those that are reasonable and necessary for the diagnosis or treatment of an illness or injury and that are given at the appropriate level of care 或计划另有规定. 第三条. A. (4) (a) of the 雇主 Benefit Plan provides benefits for insulin and prescription drugs (which by Federal or State law require a 医生tor’s written prescription) dispensed by a licensed pharmacist, and prescribed by a physician for treatment or control of an illness or a non-occupational accident.
Viagra was approved by the Food and Drug Administration (FDA) on March 27, 1998, to treat impotence. It is Funds’ policy to provide coverage for six Viagra tablets per month based on the following guidelines: 1) The patient is of male gender; 2) The patient has documented erectile dysfunction; 3) The patient has chosen this treatment option; 4) The patient is not currently receiving any form of nitrate therapy; 5) If over age 65, the patient is initiating therapy with 25 mg dose; 6) If the patient is taking macrolide antibiotics (erythromycin, Biaxin, Zithromax), 酮康唑(Nizoral), 伊曲康唑(拉米西)或西咪替丁(他加美)起始剂量已减至25mg.
A Funds’ medical consultant has reviewed this file and notes that the documentation submitted indicated that the penis was bent. 然而, the documentation does not indicate that there was a problem with erection in regard to blood flow or with nerves associated with the erection process. 此外, the medical consultant indicated that the documentation submitted does not establish that there is in fact a problem with an erection. 因此, 根据提交的文件, 被告不需要为伟哥提供保险.
受托人的意见
被告不需要为处方药伟哥提供保险.