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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-760 – February 6, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and
Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for diagnostic services under the terms of the Employer Benefit Plan.
Background Facts
Following the orders of her physician, a doctor of podiatric medicine (D.P.M.), the Employee’s spouse had two x-rays of her feet taken in the outpatient department of a local hospital on June 3, 1992. The charges for the two x-rays totalled $144.60. The Employer denied benefits for the x-rays. In a statement dated March 10, 1993 the Employee’s spouse’s physician said that the x-rays were necessary for pre-operative evaluation of an orthopedic deformity. The Employer stated that the two x-rays constituted routine care of the feet.
Dispute
Is the Employer required to provide benefits for the two x-rays taken of the Employee’s spouse’s feet on June 3, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the x-rays taken of the Employee’s spouse’s feet since they were ordered by her attending physician, and diagnostic x-rays are an eligible expense under the terms of the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the x-rays because they constituted routine care of the feet.
Pertinent Provisions
Article III.A.(2)(c) of the Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(c) Laboratory Tests and X-rays
Benefits are provided for laboratory tests and x-ray services performed in the outpatient department of a hospital which provides such services and when they have been ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Article III.A.(3)(n) of the Employer Benefit Plan states in pertinent part:
(n) Primary Care – Podiatrists’ Services
Benefits are provided for minor surgery rendered by a qualified licensed podiatrist. Routine care of the feet such as trimming of nails, the treatment of corns, bunions (except capsular or bone surgery therefor) and calluses is excluded…
Question and Answer (Q & A) #81-43 states:
Subject: Routine Foot Care
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (m) and (n)
Under the Podiatrist’s Services benefit, benefits are provided for the following services when rendered by a qualified licensed podiatrist:
(1) Minor surgery
(2) Major surgery when performed in a hospital after prior approval has been received from the Plan Administrator.
Routine care of the feet such as trimming of nails, treatment of corns, bunions (except capsular or bone and surgery therefor) and calluses is expressly excluded.
Question:
1. Are benefits provided for routine foot care when a Beneficiary has diabetes, peripheral vascular disease or peripheral neuropathy of the foot?
2. Are benefits provided for non-routine podiatric services rendered for treatment of such problems as tendinitis, ruptured Achilles tendon, and gout covered benefits?
3. Are benefits provided for diagnostic studies (i.e., laboratory tests and x-ray) ordered or performed by a qualified licensed podiatrist in conjunction with minor or major surgery or treatment of a non-routine foot problem?
Answer:
1, 2, & 3. Yes.
Discussion
Article III.A.(2)(c) provides benefits for laboratory and x-ray studies performed in an outpatient department of a hospital when ordered by a physician for the diagnosis or treatment of a specific condition, illness or injury. Article III.(3)(n) of the Plan provides benefits for minor surgical procedures performed by a licensed podiatrist. This provision excludes charges for routine foot care, including trimming of the nails, and the treatment of corns, bunions or calluses.
Question and Answer #81-43 states that diagnostic x-rays ordered by a licensed podiatrist in conjunction with non-routine foot problems are eligible for benefits under the terms of the Employer Benefit Plan.
In this case, the Employee’s spouse’s physician stated that the x-rays were ordered for the pre-operative evaluation of the spouse’s condition, and the x-ray report was ordered to rule out hallux valgus, or misaligned great toe, along with possible bunion. Since the x-rays were taken to determine the presence of potentially non-routine foot problems, the Trustees find that the Employer is required to provide benefits for the two diagnostic x-rays taken of the Employee’s spouse’s feet on June 3, 1992.
Opinion of the Trustees
The Employer is required to provide benefits for the two x-rays taken of the Employee’s spouse’s feet on June 3, 1992.