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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-153 – October 24, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 pneumococcal vaccinations under the terms of the Employer Benefit Plan.
Background Facts
A physician has diagnosed both the Employee and his spouse as having recurrent upper respiratory infections. On October 17, 1988, the physician administered pneumococcal vaccinations to both of them to reduce the risk of pneumonia. The Employer denied benefits for the pneumococcal vaccinations, stating that such routine services are not covered under the Employer Benefit Plan.
Dispute
Is the Employer required to provide health benefits for the pneumococcal vaccinations administered to the Employee and his spouse?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for the pneumococcal vaccinations because both the Employee and his spouse are at risk of developing pneumonia.
Position of the Employer: The Employer is not required to provide benefits for the pneumococcal vaccinations because they are routine services which are not covered under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (3) (o) 2. of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(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 immunizations when medically necessary.
In this case, a physician administered pneumococcal vaccinations to the Employee and his spouse because of their recurrent upper respiratory infections. A Funds’ medical consultant has reviewed the information submitted in this file. The medical consultant states that although the vaccination will not prevent all pneumonias, it is used as a treatment to prevent some of the more common pneumococcal infections in high-risk patients. The medical consultant concurs with the prescribing physician that both patients in this case have respiratory problems that make the pneumococcal vaccinations medically necessary. Inasmuch as the medical necessity of the pneumococcal vaccinations has been established, they are covered under Article III. A. (3) (o) 2. of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide health benefits for the pneumococcal vaccinations administered to the Employee and his spouse.