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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-738 – December 10, 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 the provision of health benefits coverage for orthoptics under the terms of the Employer Benefit Plan.
Background Facts
A Doctor of Optometry states that the Employee’s son suffers from binocular fusion disorder, oculomotor dysfunction, accommodative deficit, and saccadic deficit, and that these conditions can cause pathological diplopia, unstable focus, and severe ocular discomfort. He notes that these conditions may require surgery, but that early intervention with orthoptic treatments generally results in permanent resolution of the condition. He further recommends that the son receive 20-25 one hour orthoptic treatments (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) at $82.00 per session. The son’s doctor stated that the long and short term prognoses would be excellent after the proposed treatments.
The Employer has stated that the treatments are specifically excluded under Article III.A.(9)(c)4. of the Employer Benefit Plan and thereby informed the Employee’s son’s optometrist that the treatments, if undertaken, would be ineligible for benefits under the Plan.
The Employee has stated that Article III does not exclude this type of treatment and, therefore, it is the responsibility of the carrier to provide benefits for these treatments.
Dispute
Is the Employer required to provide benefits for orthoptic treatments for the Employee’s son?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the orthoptic treatments recommended for the Employee’s son since Article III does not specifically exclude this type of treatment.
Position of the Employer: The Employer is not required to provide benefits for the orthoptic treatments recommended for the Employee’s son since Article III.A.(9)(c)4. of the Employer Benefit Plan specifically excludes orthoptic treatments.
Pertinent Provisions
Article III.A.(9)(c)4. states:
(9) Vision Care Program
(c) Exclusions include:
4. special procedures, such as orthoptics, vision training, subnormal vision aids, aniseikonic lenses and tonography;
Article III. A. (11) (a) 27 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:
27. Any types of services, supplies or treatments not specifically provided by the Plan.
Discussion
Article III. A. (9)(c) 4. of the Employer Benefit Plan states that special procedures such as orthoptics and vision training are specifically excluded from coverage under the vision care program of the Plan. Article III. A. (11) (a) 27. of the Employer Benefit Plan states that any service not specifically provided by the terms of the Plan is excluded from coverage.
Inasmuch as orthoptics are specifically excluded from coverage under the vision care program, and the medical portion of the Plan contains no provision for orthoptics, the orthoptic treatments recommended for the Employee’s son would not be eligible for benefits under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for orthoptic treatments as proposed for the Employee’s son.