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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-458 – May 7, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Elliot A. Segal, 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 immunizations for an Employee’s son under the terms of the Employer Benefit Plan.
Background Facts
On July 2, 1990, a physician administered TD (Tetanus and Diptheria) and MMR (Measles, Mumps, Rubella) vaccines to the Employee’s 17-year-old son. The Employee’s son was at the physician’s office for a complete checkup and to follow up on a bee sting allergy. Similarly, on November 7, 1990, the Employee’s 10-year-old daughter was given a MMR booster during an exam for treatment of “pink eye”. During each checkup, the physician reviewed his records and noted that the Employee’s children were behind in their immunizations.
The Employer’s insurance carrier has denied benefits for the Employee’s children’s immunizations, stating that neither well-child care nor immunizations are a covered benefit.
Dispute
Is the Employer required to provide benefits for the immunizations administered to the Employee’s son and daughter?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the immunizations administered-to the Employee’s son and daughter because they are covered benefit.
Position of the Employer: The Employer has not provided a statement regarding its carrier’s coverage determination.
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.
Article III. A. (11) (a) 5. of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
5. Immunizations provided by local health agencies.
Discussion
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides benefits for many preventive health measures, including immunizations, pap smears, examinations for cancer, blindness and deafness, as well as other screening and diagnostic procedures when medically necessary. With respect to these procedures, medical necessity is not necessarily construed to imply imminent danger or the actual onset of disease or illness, such as the administration of rabies vaccine after a wild animal bite, but also refers to the application of prudent medical practice and preventive care, as in the case of screenings for hypertension and diabetes.
In this case, a physician administered Tetanus and Diptheria vaccine to the Employee’s son as well as Measles, Mumps and Rubella vaccines to the Employee’s son and daughter to keep their immunizations current.
A Funds’ medical consultant has reviewed the file in this case, and advises that the immunizations were administered consistent with the standards of medical practice for routine prophylactic vaccinations. Inasmuch as the immunizations were administered consistent with professional’ guidelines for preventive health care and current standards of medical practice, the Employer is required to provide benefits for the medically necessary immunizations administered to the Employee’s son.
Opinion of the Trustees
The Employer is required to provide benefits for the immunizations administered to the Employee’s son and daughter.