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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-628 – July 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 benefits for visual field testing under the terms of the Employer Benefit Plan.
Background Facts
On January 5, 1987, an ophthalmologist conducted eye examinations and visual field testing of the Pensioner and his spouse to determine if they had any loss of peripheral vision resulting from their glaucoma and scotomata (blind spots in the visual field). The Pensioner’s spouse was blind in the left eye and had received laser treatment for an angioma (tumor composed of blood vessels) in her right eye, as well. The ophthalmologist stated that visual field testing was also necessary to follow the effectiveness of the treatment of the angioma. A computerized Fieldmaster 101 was used to perform the visual field tests.
The Employer provided benefits for the eye examinations but denied payment for the visual field testing stating that benefits are not provided under the Employer Benefit Plan for visual field tests in addition to a vision examination. The Employer has also taken the position that such testing was not medically necessary for the Pensioner and his spouse.
Dispute
Is the Employer responsible for providing benefits for the Pensioner’s and the Pensioner’s spouse’s visual field testing?
Positions of the Parties
Position of the Pensioner: The Employer is responsible for providing benefits for the Pensioner’s and the Pensioner’s spouse’s visual field testing because it was medically necessary for the treatment of their glaucoma.
Position of the Employer: The Employer is not responsible for providing benefits for the Pensioner’s and the Pensioner’s spouse’s visual field testing because benefits are not provided for it in the Employer Benefit Plan nor was it medically necessary.
Pertinent Provisions
Article III. A. (3)(o) 2. of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(c) 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.
1981 Contract Q&A #81-65 states:
Subject: Vision Care
References:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Sections A (1), (2), (3), (4), (8), (9), and (11) (a) 22
Question:
1. What benefits are provided for eye care under the Plan, other than routine eye care provided in Section A (90), Vision Care Program?
2. Are benefits provided for a medication prescribed by a physician for the treatment of an eye disease or injury?
Answer:
1. Benefits are provided for the following:
o Eye examinations (but not refractions) and the full cost of corrective glasses or contact lenses when medically required because of a surgically caused refractive error.
o Eye surgery and other treatment of eye illnesses and injuries
o Eye specialists’ care
o Replacement lenses or eyeglasses for eye surgery patients, as provided in Article III, Section (11).
2. Yes, but only for those drugs which by Federal or State law require a prescription and are dispensed by a licensed pharmacist. These drugs are subject to copayment.
Drugs used in connection with eye examinations are considered part of the cost of the examination.
Drugs prescribed in connection with the Vision Care Program are specifically excluded from coverage under Section (9) (c) 3.
Discussion
Under Article III. A. (3)(o) 2., benefits are provided for examinations for blindness and other screening and diagnostic procedures when medically necessary. Q&A #81-65 states that benefits are provided for eye surgery and other treatment of eye illnesses and injuries.
The Pensioner’s physician performed precise visual field testing on the Pensioner and his spouse to determine the effectiveness of treatment for their glaucoma and the Pensioner’s spouse’s angioma. A Funds’ medical consultant has reviewed this case and advised that the visual field testing was medically necessary in addition to routine eye examinations because of their glaucoma and the Pensioner’s spouse’s angioma. Because the visual field testing was medically necessary for the treatment of their eye illnesses, it is a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for providing health benefits for visual field testing for the Pensioner and his spouse.