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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-150 April 7, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
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 fact, and circumstances of this dispute concerning the provision of health benefits for a procedure to reverse sterilization under the terms of the Employer Benefit Plan.
Background Facts
The physician of the Employee’s spouse submitted to the Employer a request for consideration of health benefits coverage for a proposed tubal reanastamosis. The Employer notified the physician on November 14, 1985 that the procedure, the purpose of which is to reverse sterilization, would not be covered.
On December 10, 1985, the Employer’s insurance carrier notified the Employee that approval was granted for payment for the procedure within the reasonable and customary amounts established for this type of surgery. The Employee then contacted both the Employer and the insurance carrier by telephone on January 24, 1986 and was advised that the approval dated December 10, 1985 was in error. The procedure to reverse sterilization has not been performed.
Dispute
Is the Employer responsible for the provision of health benefits coverage for a procedure to reverse sterilization?
Position of the Parties
Position of the Employee: The Employer is bound by the representations of its agent and must therefore provide payment for the reasonable and customary charges associated with the reversal of sterilization procedures.
Position of the Employer: The Employer is not responsible for payment of charges associated with the reversal of sterilization procedures because it is not a covered benefit under the Employer Benefit Plan. The insurance carrier’s authorization was in error. It is unfortunate that such an error was made, but no procedures were performed as a result of the erroneous notification.
Pertinent Provisions
Article III. A. (11) (a) of the Employer Benefit Plan states in part:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
14. Charges for reversal of sterilization procedures.
Discussion
Under Article III. A. (11) (a) of the Employer Benefit Plan, charges associated with reversal of sterilization procedures are not covered. The Employer duly notified the Employee’s wife’s physician of this on November 14, 1985. The authorization notice of December 10, 1985 was not consistent with the terms of the Employer Benefit Plan. That authorization notification was made in error, and the Employee was so informed before the sterilization reversal procedure was performed. The Employer is not responsible for providing benefits which are specifically excluded under the Plan.
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits coverage for the Employee’s wife’s proposed reversal of sterilization procedures.