OPINION OF TRUSTEES
ROD Case No: 81-110 November 2, 1983
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article IX of the United Mine Workers of America 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 health coverage for physician extender services and hereby render their opinion on the matter.
The Employee underwent a cystourethroscopy on December 28, 1981 and a transurethral resection of the prostate on December 30, 1981, During those procedures the services of a physician aide/assistant were utilized.
The Employer provided benefits for the surgical, anesthesia and hospital fees related to these procedures, but denied payment for the services of the physician aide/assistant.
Question or Dispute
Is the Employer responsible for coverage of the charges for the services of a physician aide/assistant utilized during the Employee’ surgery.
Positions of the Parties
Employee’s Position: The Employee contends that the Employer should pay for the services of the physician aide/assistant utilized during the surgical procedures he underwent because the attending surgeon determined that his services were necessary during these procedures.
Employer’s Position: The Employer contends that the services of the physician aide/assistant are not covered by the Employer’s Benefit Plan since he is not licensed to practice medicine or surgery and because he does not satisfy the qualifications of a surgical assistant.
Article III. A. 3 (o) 4 of the Employer’s Benefit Plan provides:
4. Benefits are provided for “physician extender” care or medical treatment administered by nurse practitioners, physician’s assistants or other trained, certified and/or Licensed health personnel when such service is rendered under the supervision of a physician.
Under Article III. A. (3) (o) 4 of the Employer’s Benefit Plan, benefits are provided for “physician extender” care or medical treatment administered by nurse practitioners, physician’s assistants or other trained certified and/or licensed health personnel when such service is rendered under the supervision of a physician. According to the information available to the Trustees, the physician aide/assistant who provided services during the Employee’s surgical procedures is not licensed, registered or certified. Therefore, the services provided by the physician aide/assistant during the Employee’s surgical procedures are not covered benefits under the Employer’s plan.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for providing benefits for services rendered by a physician aide/assistant during the Employee’s surgery on December 28, 1981 and on December 30, 1981.