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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-015 – June 6, 1996
Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
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 daughter has been diagnosed with convergence insufficiency and oculomotor dysfunction, conditions in which her eyes fail to point properly at near tasks and lack synchronization of movement. She was examined by an optometrist who recommended that she undergo a series of orthoptic treatments. These treatments involve eye exercises to strengthen the eye muscles and improve binocular cooperation of the eyes.
The Employer denied the preauthorization request for benefits.
Dispute
Is the Employer required to provide benefits for the orthoptic therapy sessions for the Employee’s daughter?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the orthoptic therapy because they are treatment for a medical condition.
Position of the Employer: The Employer is not required to provide benefits for the orthoptic therapy because such therapy is not covered under the medical provisions of the Employer Benefit Plan, and 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:
(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. 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 orthoptics services provided to the Employee’s daughter are not covered under the Employer Benefit Plan.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for orthoptic services for the Employee’s daughter.