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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-581 – April 26, 1988

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 facts and circumstances of this dispute concerning the provision of health benefits under the terms of the Employer Benefit Plan.

Background Facts

The Employee was asked by the Employer to complete a form requesting information to be used in the event of a medical emergency. One of the questions on the form asked for the Employee’s blood type. Since he was not sure of his blood type, the Employee went to his doctor on March 20, 1987 for blood typing, incurring charges for the office visit and laboratory test totaling $58.00. The representative for the Employee contends that the Employer should be responsible for payment of the charges in dispute since such charges were incurred by the Employee in the course of his employment in response to a request by the Employer.

The Employer has refused to pay the charges in question stating that there is no indication that the services were medically necessary for the diagnosis or treatment of an illness or injury, and that completion of the form was not a condition of employment. The Plan Administrator has indicated that the form was sent. to all Employees by U.S. mail with no additional instructions other than to complete and return the form; no other claims for blood tests have been submitted for payment by any other Employees responding to the questionnaire.

Dispute

Whether the Employer is responsible for payment of the charges related to the Employee’s blood work on March 20, 1987.

Positions of the Parties

Position of the Employee: The Employer is responsible for payment of the charges related to the Employee’s blood work since such charges were incurred by the Employee in the course of his employment in response to a request by the Employer.

Position of the Employer: The Employer is not responsible for payment of the charges related to the Employee’s blood work because the services were not medically necessary for the diagnosis or treatment of an illness or injury and because completion of the form as requested by the Employer was not a condition of employment.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan provides 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)(j) of the Employer Benefit Plan provides:

(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.

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.

Article III. A. (3)(o) 2. of the Employer Benefit Plan provides:

(o) Primary Medical Care – Miscellaneous

2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness, and other screening and diagnostic procedures when medically necessary.

Discussion

The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. Article III. A. (3)(j) of the Plan states that benefits will be provided for laboratory tests and x-rays when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury. In addition, Article III. A. (3)(o) 2. of the Plan states that benefits are provided for screening and diagnostic procedures when medically necessary.

Although the Employee incurred charges for a blood test in order to accurately complete a form for the Employer’s records, there is no evidence that he was required to do so as a condition of employment. It is undisputed that the services in question were rendered to determine the Employee’s blood type. The services were not ordered by a physician as medically necessary for the diagnosis or treatment of a definite condition, illness or injury. Therefore, the Employer is not responsible for payment of the charges related to the Employee’s blood work on March 20, 1987.

Opinion of the Trustees

The Employer is not responsible for payment of the charges related to the Employee’s blood work on March 20, 1987.