_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-046 – June 27, 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 chromatography and immunoassay under the terms of the Employer Benefit Plan.
Background Facts
On May 25, 1994, the Employee’s spouse was referred for chromatography and immunoassay diagnostic services. Both are generally recognized diagnostic chemistry laboratory tests. The Employer has denied benefits, stating that there are no procedures in the benefit manual that encompass these services.
Dispute
Is the Employer required to provide benefits for chromatography and immunoassay diagnostic testing?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for chromatography and immunoassay diagnostic tests because the Employer Benefit Plan includes diagnostic laboratory tests as a covered service.
Position of the Employer: The Employer is not required to provide benefits for chromatography and immunoassay diagnostic tests because there are no procedures in the benefit manual that encompass these services.
Pertinent Provisions
Article III A. (3) (j) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
Discussion
Article III A.(3) (j) provides benefits for laboratory tests that are ordered by a physician for the diagnosis or treatment of an illness or injury. Chromatography and immunoassay are recognized chemistry laboratory procedures that are approved by Medicare and the Funds. Therefore, consistent with Medicare and Funds practice, the Employer is required to provide benefits for these tests.
Opinion of the Trustees
The Employer is required to provide benefits for the chromatography and immunoassay laboratory tests for the Employee’s spouse.