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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-052 – October 10, 1996
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 diagnostic services under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son was referred for evaluation of his condition at the request of his school. A psychiatrist and a pediatrician conducted diagnostic examinations, and both concurred that the Employee’s son had Attention Deficit Disorder (ADD). This has been defined as developmentally inappropriate inattention and impulsivity, with or without hyperactivity, and is a condition that manifests itself, in part, as a behavioral problem. The medications often prescribed for the treatment of ADD can produce severe side effects. Therefore, baseline and regular follow-up screening of blood levels are necessary to produce maximum treatment results with minimum side effects.
The Employer has denied benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime as treatment for a school related behavior problem, and thus not subject to benefits under Section III. A. (7) (f) 3. of the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime because they were medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime because they are part of treatment for school related behavioral problems, which are not subject to benefits under Article III. A. (7) (f) 3. of the Employer Benefit Plan.
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. . . .
Article III A. (3) (h) and (j) state in pertinent part:
(h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.
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(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Article III A. (7) (f) 3. states in pertinent part:
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for: Psychotherapy, psychological testing, counseling, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically required by a physician.
Benefits are not provided for:
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3. School related behavioral problems.
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those that are medically necessary for the diagnosis and treatment of an illness or injury. Article III A. (3) (h) provides benefits for physician office visits. Article III A. (3) (j) provides benefits for laboratory tests when they are ordered by a physician and performed by a licensed laboratory. Article III A. (7) (f) 3. excludes benefits for treatment of school related behavioral problems.
The Employer has denied benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime as part of the treatment for a school related behavioral problem, and thus ruled out by Article III A. (7) (f) 3. Although ADD is a condition that can produce behavior aberrations, including hyperactivity, at any time, it often becomes prominent when a child cannot follow the structured regimen of the classroom. However, the onset of ADD is frequently before school age, and ADD is not defined as school-related in standard medical texts such as the American Psychiatric Association’s Diagnostic and Statistical Manual-IV.
Treatment of ADD includes medication that is to be given at regular intervals to obtain optimum results throughout the day. Because of the intensity of the medication, it is necessary to periodically monitor blood chemistry levels to prevent toxicity.
The diagnostic evaluations and laboratory testing were necessary to diagnose accurately the nature of the Employee’s son’s problem as ADD, to rule out other causes and to prescribe appropriate treatment. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime related to the diagnosis and treatment of the Employee’s son’s ADD.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the diagnostic evaluations, the baseline laboratory tests, and the physician’s visit to begin the medication regime related to the diagnosis and treatment of the Employee’s son’s ADD.