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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-026 – March 4, 1997
Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr., and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for infertility drugs under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has been unable to conceive and her gynecologist has prescribed medication to induce ovulation on a regular cycle. It is anticipated that with a regular menstrual cycle, her opportunity to conceive will be increased. The Employer has denied benefits for this prescription drug.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s infertility medication?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the spouse’s medication because it is for the treatment of an illness.
Position of the Employer: The Employer is not required to provide benefits for the spouse’s medication because it is not for the treatment of a pathological disorder.
Pertinent Provisions
The Introduction to Article III 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. . . .
Article III. A. (4) (a) states in pertinent part:
(4) Prescription Drugs
(a) Benefits Provided
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 nonoccupational accident or (ii) licensed dentist for treatment following the performance of those oral surgical services set forth in (3)(e).
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those that are necessary for the diagnosis or treatment of an illness or injury. Article III. (4) (a) provides benefits for prescription drugs when dispensed by a licensed pharmacist and prescribed by a physician for treatment or control of an illness.
Drugs that regulate (or control) the ovulation and menstrual cycles are an integral part of the treatment of a female’s infertility. In this case, a physician ordered a drug that requires a prescription and the medication was dispensed by a licensed pharmacist. Therefore, consistent with Funds’ policy and practice, benefits should be provided for the infertility drugs for the Employee’s spouse.
Opinion of the Trustees
The Employer is required to provide benefits for the Employee’s spouse’s infertility drugs.