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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-639 – 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 health benefits for a colonoscopy under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse’s physician referred her to a gastroenterologist at age 34 because the Employee’s spouse’s mother had developed colon carcinoma before she was 50 years old. The gastroenterologist recommends that patients with a positive family history of cancer undergo a screening colonoscopy in their mid-thirties. On September 25, 1987, the Employee’s spouse underwent a colonoscopy in the outpatient unit of a hospital.
The Employer paid the hospital’s facility charges for the colonoscopy in full. The Employer has denied the gastroenterologist’s professional charges on the basis that the Employee’s spouse did not have any medical complaints or symptoms to justify the procedure and thus did not receive services for the diagnosis or treatment of an illness as is required for coverage under the Employer Benefit Plan.
Dispute
Is the Employer responsible for payment of the physician’s charges for the Employee’s spouse’s colonoscopy performed on September 25, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the physician’s charges for the Employee’s spouse’s colonoscopy because the Employee’s spouse has a positive family history of colon carcinoma.
Position of the Employer: The Employer is not responsible for payment of the physician’s charges for the Employee’s spouse’s colonoscopy because the Employee’s spouse did not have any medical complaints or symptoms to justify the procedure.
Pertinent Provisions
Article III. A. (3) (o) 2. of the Employer Benefit Plan states:
(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
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides benefits for examinations for cancer when medically necessary. The Employee’s spouse’s gastroenterologist performed a cancer screening colonoscopy on her because her mother had developed colon carcinoma before she was 50 years old. A Funds’ medical consultant has examined the documentation in this case and advised that the colonoscopy was medically necessary given the Employee’s spouse’s strong family history of metastatic colon cancer at a young age. Because the Employee’s spouse’s colonoscopy is a medically indicated examination for cancer, the physician’s professional services associated with the procedure are a covered benefit.
Opinion of Trustees
The Employer is responsible for payment of the physician’s charges for the Employee’s spouse’s colonoscopy performed on September 25, 1987.