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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-408 - 1991年9月12日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,受托人.
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 eye surgery under the terms of the 雇主 Benefit Plan.
背景事实
1991年1月, 眼科医生建议该员工接受放射状角膜切开术, 在角膜上做切口以矫正近视的手术. 在提交给雇主保险公司的信件中, 眼科医生说, 没有校正, the 员工 has less than 20/200 vision and is legally blind; with glasses, 他的视力正常。. The ophthalmologist stated that the 员工 is a good candidate for the proposed surgical procedure and that there is a good chance he will have close to normal or normal vision after the proposed surgery, 没有校正.
雇主拒绝给拟议的手术提供津贴.
争端
雇主是否须为雇员拟进行的眼科手术提供福利?
双方立场
Position of the 员工: The 员工 asks whether the 雇主 is required to provide benefits for the proposed eye surgery.
Position of the 雇主: The~雇主 is not required to provide benefits for the proposed eye surgery because it is an elective procedure of unproven value that is not medically necessary for the treatment of an illness or injury and its use is considered experimental.
相关的规定
雇主福利计划第三条导言规定:
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. 将继续提供医疗上必要的承保服务, and accordingly this paragraph shall not be construed to detract from coverage or eligibility as described in this 第三条.
第三条. A. (3) (a)雇主福利计划的相关部分规定:
(3) 医生服务和其他初级保健
(a) 手术的好处
Benefits are provided for surgical services essential to a Beneficiary’s care consisting of operative and cutting procedure (including the usual and necessary post-operative care) for the treatment of illnesses, 受伤, 骨折或脱位, 哪些是由医生在医院内或医院外进行的.
第三条. A. (9)(c) 5. 的相关部分指出:
(9) 视力保健计划
(c) 除外责任包括:
5. 实验服务或用品.
第三条. A. (11) (a) 24. 的“雇主福利计划”规定:
(11) 一般的除外
(a) 除本计划中另有规定的特定除外事项外, 以下情况也不提供福利:
24. Charges for treatment with new technological medical devices and therapy which are experimental in nature.
讨论
根据第三条. A. (3) (a)雇主福利计划, benefits are provided for surgical services essential to a beneficiary’s care for the treatment of illnesses, 受伤, 骨折或脱位, 这些都是由医生在医院里或医院外进行的. The Introduction to 第三条 of the 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. The Introduction further states that services that are not reasonable and necessary shall include procedures that are of unproven value or of questionable current usefulness. 此外，第三条. A. (9)(c) of the Plan excludes benefits under the vision care program for experimental services, 和第三条. A. (11) (a) 24. states that benefits are also not provided for treatment with new technological medical devices and therapy that are experimental in nature.
雇主已声明，拟议的外科手术, 前项, 在这种情况下没有医学上的必要吗, 但这是一种可选的程序，价值未经证实，被认为是实验性的. ROD 84-222(附件副本), 这是1986年10月决定的吗, the Trustees determined that 前项 was regarded as experimental by 医疗保险, 美国眼科学会和UMWA 1950年和1974年的福利计划, 因此, 这不是雇主福利计划所涵盖的福利.
根据现行的医疗保险规定, 任何形式的屈光角膜移植术, 包括桡骨角膜切开术, 因为还在调查中所以不包括在内吗, 并没有在人体中进行充分的科学评估. 除了, 前项 is still regarded as experimental by the UMWA 1950 and 1974 Benefit Plans. An assessment of 前项 for myopia was published by the American Academy of Ophthalmology in September 1988. 如雇主所述, this publication concludes that the operation of 前项 is undergoing evolution and development. The assessment also indicates that current techniques of 前项 do not allow accurate prediction of the outcome in individual eyes and that the predictability achieved in fitting eyeglasses and contact leases is more accurate.
A Funds’ medical consultant has reviewed this case and has advised that the proposed surgery of 前项 is not medically necessary to correct the 员工’s vision of 20/200 because that impairment is currently corrected by conventional treatment. The consultant also states that this procedure is still considered experimental in nature because its safety and efficacy have not been established.
Inasmuch as the proposed surgery of 前项 is not medically necessary for treatment of the 员工’s visual impairment and is considered experimental in nature, 它不是雇主福利计划所涵盖的服务.
受托人的意见
The 雇主 is not required to provide benefits for the 员工’s proposed eye surgery.