OPINION OF TRUSTEES
ROD Case No: 88-612 – June 25, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee;
Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
The Trustees have reviewed the facts and circumstances of this dispute concerning benefits for a pre-operative physical examination under the terms of the Employer Benefit Plan.
On September 23, 1991 the Employee’s 16-year-old daughter underwent a pre-operative physical examination and attendant laboratory work totalling $108.00 in preparation for the extraction of her wisdom teeth under general anesthesia. The daughter’s attending physician stated that the reasons the oral surgeon had requested this examination was that the child was blind after having both eyes removed as an infant, possibly due to a viral infection, and because the daughter’s obesity had worsened in the recent past. She weighs 226 pounds and is 5’5″ tall. The record shows that the last physical examination performed on the Employee’s daughter was more than two years ago. The oral surgeon felt that these factors warranted a pre-operative physical prior to the administration of a general anesthetic.
The Employer denied the charges, stating that blindness was not a medical condition which would justify the examination under Article III.A.(3)(o) 3., and that there were no other underlying pre-existing medical conditions that would have necessitated the examination.
Is the Employer required to provide benefits for the Employee’s daughter’s pre-operative physical examination performed on September 23, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the pre-operative physical examination performed on the Employee’s daughter on September 23, 1991 because the examination was requested by the oral surgeon performing the surgical procedure.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s daughter’s pre-operative physical examination as routine physical examinations are ineligible under the terms of the Employer Benefit Plan and there was no underlying medical problem necessitating the examination.
The Introduction to Article III states in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis and treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan…..
Article III.A.(3)(e) states:
(e) Oral Surgery
Benefits are not provided for dental services. However, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or oral surgeon:
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, only when medically necessary and related to an orthopedic problem.
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Article III.A.(3)(o) 3. states:
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.
Article III.A.(11) 15. states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
15. Charges in connection with a general physical examination, other than as specified in this Plan.
The Introduction to Article III provides benefits for services which are reasonable and necessary for the care and treatment of an illness or injury, which are given at an appropriate level of care, or which are otherwise covered under the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is reasonable or necessary or that it is covered under this Plan. Article III.A.(3)(o) 3. provides benefits for routine physical examinations under limited circumstances. And, Article III.A.(11) 15. excludes charges for general physical examinations, other than those provided for under Article III.A.(3)(o) 3.
The Employee’s daughter is severely obese and is blind due to a loss of both eyes as an infant, possibly due to a viral infection. Based on the fact that the Employee’s daughter’s last physical examination had taken place over two years ago, and because her obesity had worsened recently, the oral surgeon requested a pre-operative physical examination be done by her regular family physician. A Funds’ medical consultant has reviewed the facts of this case and has discussed it with the Employee’s daughter’s family physician. The consultant concluded that there was sufficient documentation to justify the physical examination as medically appropriate since it was prescribed by a specialist as part of the specialist’s care of the daughter’s medical condition.
Since the pre-operative physical would be considered eligible under Article III.A.(3)(o)3.(iv), the exclusion contained in Article III.A.(11) 15. would not apply.
Therefore, the Trustees find that the Employer’s denial of benefits for the Employee’s daughter’s pre-operative physical examination on September 23, 1991 was not appropriate, given the facts and circumstances of the case.
Opinion of the Trustees
The Employer is required to provide benefits for the Employee’s daughter’s pre-operative physical examination on September 23, 1991.