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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-399 – July 13, 1988
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for diagnostic tests under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son was referred by his family physician to a clinic for diagnostic testing and evaluation of his complaints, which included lightheadedness, tinnitus, tachycardia, temperature alterations, chest pain, diarrhea, headaches, a burning sensation in his neck and lower back, insomnia, and unexplained weight loss.
The clinic performed a number of tests on the Employee’s son in order to establish accurate diagnoses upon which to base further treatment. The Employer paid benefits for most of the tests but denied coverage for some on the basis that they were not medically necessary.
Dispute
Is the Employer responsible for providing benefits for all of the diagnostic tests performed on the Employee’s son?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing benefits for all of the diagnostic tests performed on the Employee’s son.
Position of the Employer: The Employer is not responsible for providing benefits for certain of the diagnostic tests because they were routine and not medically necessary.
Pertinent Provisions
Article III. A. (3)(o) 2. of the Employer Benefit Plan states in part:
2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness and other screening and diagnostic procedures when medically necessary.
Discussion
Under Article III. A. (3)(o) 2. of the Employer Benefit Plan, health benefits coverage is provided for diagnostic procedures when they are medically necessary. A Funds’ physician consultant has reviewed the case and advised that the tests for which the Employer denied coverage (i.e., tonometry, spirometry, stress test, ultrasound of the abdomen and orthorater) were indicated given the Employee’s son’s complaints. These tests were, therefore, medically necessary for the diagnosis of specific conditions, and are covered under Article III. A. (3)(o) 2.
Opinion of the Trustees
The Employer is responsible for providing health benefits for all of the diagnostic tests performed on the Employee’s son.