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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: CA-035 – March 23, 1999
Trustees: A. Frank Dunham, Michael H. Holland, Marty D. Hudson and
Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for screening mammography under the terms of the Coal Industry Retiree Health Benefits Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
Background Facts
On April 30, 1997, the Pensioner’s spouse, age 60, had an annual screening mammogram. For several years, through the Employer’s Health Fairs, the Employer promoted regular screening mammograms and the Employer’s insurance carrier provided benefits for them. In 1997, the Employer’s new insurance carrier interpreted the Employer’s Benefit Plan to require the presence of a medical condition before providing benefits for routine tests such as a screening mammogram. Although the Pensioner’s spouse’s screening mammogram was requested by her physician, the Employer’s new insurance carrier denied coverage due to a lack of medical necessity.
The provider of the mammogram service is a Food and Drug Administration-certified mammography center.
Dispute
Is the Employer required to provide benefits for the Pensioner’s spouse’s screening mammogram?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the Pensioner’s spouse’s screening mammogram because it is an examination for cancer and was ordered by her physician.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s spouse’s screening mammogram because there was no indication of medical necessity.
Pertinent Provisions
The Introduction to Article III of the Coal Act Employer Benefit Plan states, in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in this Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
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Article III A. (3) (o) 2. of the Coal Act Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(o) Primary Medical Care – Miscellaneous
2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness, and other screening and diagnostic procedures when medically necessary.
Discussion
The Introduction to Article III of the Coal Act Employer Benefit Plan limits covered services to those that are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. Article III A. (3) (o) 2. of the Plan provides benefits for preventive health measures including immunizations, pap smears, and examinations for cancer, blindness and deafness, as well as other screening and diagnostic procedures when medically necessary. With respect to these procedures, medical necessity is not necessarily construed to imply imminent danger or the actual onset of disease or illness but also refers to the application of prudent medical practice and preventive care.
In this case, the Employer’s insurance carrier denied coverage for a screening mammogram of the Pensioner’s 60 year old spouse. Since January 1991, Medicare has provided benefits for screening mammograms for women over age 40 (without a physician’s prescription or referral), when rendered at a Food and Drug Administration-certified mammography center. Screening mammograms for women over age 40 also fall within the guidelines of the National Cancer Institute (NCI) for the detection and prevention of breast cancer. In ROD 88-371 (copy enclosed herein), the Trustees addressed a similar issue concerning coverage for preventive care under the Employer Benefit Plan. Inasmuch as the Pensioner’s spouse’s screening mammogram was administered consistent with professional guidelines for preventive health care, the Employer is required to provide benefits for the Pensioner’s spouse’s screening mammogram on April 30, 1997.
Opinion of the Trustees
Consistent with the provisions of the Coal Act Employer Benefit Plan, the Employer is required to provide benefits for the Pensioner’s spouse’s screening mammogram on April 30, 1997.