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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-482 – 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 routine office visits under the terms of the Employer Benefit Plan.

Background Facts

On September 17, 1991, the Employee’s three dependent children, ages 16, 13 and 7, were seen by a physician in his office for routine medical care. Additionally, the physician administered immunizations to two of the children.

The Employer provided benefits for the immunizations, but denied benefits for the office visits, stating that routine office visits for children over the age of six are not covered under the Employer Benefit Plan.

Dispute

Is the Employer required to provide benefits for the physician’s charges resulting from the office visits of the Employee’s children on September 17, 1992?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the office visits because office visits are covered by the Plan.

Position of the Employer: The Employer is not required to provide benefits because the office visits were not provided for the treatment of an illness or injury and are not otherwise provided for in the Plan.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan states in pertinent part:

Article III – Benefits

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)(h) of the Employer Benefit Plan states:

(3) Physicians’ Services and Other Primary Care

(h) Home, Clinic, and Office Visits

Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.

Article III. A. (3)(o) 1 and 3 state:

(o) Primary Medical Care – Miscellaneous

1. Benefits are provided for care of newborn babies and routine medical care of children prior to attaining age 6.

3. Benefits are provided for physical examinations when certified as medically necessary by a physician. Medically necessary will mean that a Beneficiary (i) has an existing medical condition under treatment by a physician, (ii) has attained age 55, (iii) is undergoing an annual or semi-annual routine examination by a gynecologist or (iv) is undergoing a routine examination prescribed by a specialist as part of such specialist’s care of a medical condition.

Discussion

The Introduction to Article III of the Employer Benefit Plan states that covered services are 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)(h) of the Plan provides benefits for services rendered to a Beneficiary at home, in a clinic, or in a physician’s office for the treatment of illnesses or injuries, if provided by a physician. Article III A. (o) 1 and 3 further define covered physical examinations as care provided to newborn babies; routine care of children prior to attaining age 6; and physical examinations when certified as medically necessary by a physician. Medically necessary means that a Beneficiary has an existing medical condition under treatment by a physician, has attained 55 years of age, is undergoing an annual or semi-annual routine examination by a gynecologist, or is undergoing a routine examination prescribed by a specialist as part of the specialist’s care of a medical condition.

In this case, the physician provided routine physical examinations to the Employee’s three dependent children. The Employee has not questioned the routine diagnosis. The Employee has stated that the insurance company changed “office visits” to “physical exams” and refused to pay, but this change in terminology was not the cause for the denial of benefits for the office visits in question. Inasmuch as benefits can be provided for physician office visits only for the evaluation or treatment of an illness or injury, except under specific conditions that do not exist in this case, the Trustees conclude that the Employer is not required to provide benefits under the Employer Benefit Plan for the physician’s charge for office visits on September 17, 1991.

Opinion of the Trustees

The Employer is not required to provide benefits for the physician’s charges resulting from the office visits of the Employee’s dependent children on September 17, 1991.