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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-851 – July 12, 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 orthoptics under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son has been diagnosed with convergence insufficiency, a condition in which his eyes fail to point properly at near tasks. He was treated by an optometrist with orthoptic/pleoptic therapy sessions, which involved eye exercises to strengthen the eye muscles and assure proper binocular cooperation of the eyes. The procedures in question took place in 1992.
The Employer has denied benefits for these visual therapy sessions.
It should be noted that, in the initial Request for Resolution of Dispute, two other issues were included. Those two issues were subsequently resolved and are no longer a part of this Resolution of Dispute.
Dispute
Is the Employer required to provide benefits for the orthoptic/pleoptic therapy sessions for the Employee’s son?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the orthoptic/pleoptic services because a representative of the insurance carrier said they would be covered.
Position of the Employer: The Employer is not required to provide benefits for the orthoptic/pleoptic services because such therapy is specifically excluded under the vision care provisions of the Employer Benefit Plan.
Pertinent Provisions
Article III A. (9) (c) 4 of the Employer Benefit Plan states:
Article III Benefits
A. Health Benefits
(9) Vision Care Program
(c) Exclusions include:
4. special procedures, such as orthoptics, vision training, subnormal vision aids, aniseikonia lenses and tonography;
Article III A. (11) (a) 27 of the Employer Benefit Plan states:
Article III Benefits
A. Health Benefits
(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.
Since orthoptics and vision training are specifically excluded from coverage under the vision care program and the medical portion of the Plan contains no provision for visual therapy, the visual therapy services provided to the Employee’s son are not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the orthoptic/pleoptic therapy sessions for the Employee’s son.