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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-175, July 25, 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 payment of laboratory tests and x-rays and hereby render their opinion on the matter.
Background Facts
On June 28, 1982, the Employee and his spouse were referred by their family doctor to a clinic for professional services. The Employee as referred for evaluation of chest pain, left shoulder pain, pain in the right testicle and groin, and problems with urinating. His spouse was referred for pain in both hips and shoulders.
A history and physical examination with a standard battery of tests and procedures were performed. The Employer has denied payment for the following tests: Tonometry (eye test), Audiogram (hearing test), Sigmoidoscopy (exam of the colon), and Orthorater (eye exam) for both patients. In addition, payment was denied for the Employee’s EKG.
Dispute
Is the Employer responsible for the charges for the laboratory tests and x-rays that were denied?
Position of the Parties
Position of Complainant: The Employer should pay the balance of the unpaid accounts.
Position of Respondent: The series of diagnostic services are not covered under the Plan and have no relationship to the definitive condition.
Pertinent Provisions
Article III. A. (3)(j) of the Employer’s Benefit Plan provides:
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 delicate condition, illness or injury.
Such benefits will not cover laboratory tests and x-rays ordered in connection with a routine physical examination, unless the examination is considered medically necessary by a physician.
Discussion
Under Article III. A. (3)(j) of the Employer’s Plan, benefits are provided for laboratory tests and x-ray services performed in a licensed laboratory when they have been ordered by a physician for diagnosis or treatment of a definite condition, illness or injury. Furthermore, laboratory tests and x-rays ordered in connection with a routine physical examination are excluded unless considered medically necessary by a physician.
The Trustees have been advised by a Funds’ medical consultant that the denied charges were for tests that did not diagnose or treat a definite condition, illness or injury. Therefore, the Employer is not responsible for payment of charges for these tests.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for the payment of charges for tests which did not treat or diagnose a definite condition, illness or injury.