______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 1981年1月27日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning coverage for an assistant podiatrist’s fee and hereby render their opinion.

背景事实

4月23日, 1980, the 员工’s dependent spouse underwent minor surgery for the removal of bilateral intermetatarsal neuroma of the foot. The surgery was performed by a licensed podiatrist in his office. 他得到了另一位足病医生的帮助. The Insurance Carrier has paid all the charges incurred as a result of the surgery, except the assistant surgeon’s fee of $82.50，但被拒绝.

争端

Is the 雇主 responsible for coverage of the assistant podiatrist’s fee?

各方立场

Position of the 原告: The 员工 is questioning the denial of the assistant surgeons fee.

Position of the Respondent (Insurance Carrier): The respondent relies on the “Surgical Benefits” section of their Plan, 他们声称:

(2) Assistance in the actual performance of the procedure, if the type and complexity of the procedure or the condition of the person on which it is performed requires such assistance and the person is a hospital inpatient when the procedure is performed.

根据该条款, 被告的结论是 the assistant podiatrist’s fee is not covered because the procedure was not performed on an inpatient basis. 除了, the respondent relies on the “Generally Excluded Charges” section of the Plan, 他们声称:

(3) Charges for unnecessary services and supplies – charges for any service or supply not reasonably necessary for the medical care of the patient’s sickness or injury; charge made by a hospital to the extent that they are allocable to scholastic education or vocational training of she patient as determined by (Insurance Carrier).

的基础上, 被告的结论是, 被认为是合理必要的, the service must be ordered by a Physician and must be commonly and customarily recognized as appropriate in the treatment of the patient’s diagnosed sickness or injury. The assistant podiatrist’s service is not considered medically necessary under this standard.

Position of Respondent (雇主): The 雇主 agrees with the Insurance Carrier’s position.

国家有关规定

第三条, Section A(3)(b) of the 雇主’s Plan provides as follows:

If the Beneficiary is an inpatient in a hospital, benefits will also be provided for the services of a physician who actively assists the operating physician in the performance of such surgical services when the condition of the Beneficiary and type of surgical service require such assistance.

第三条, Section A(3)(n) of the 雇主’s Plan provides as follows:

Benefits are provided for minor surgery rendered by a qualified licensed podiatrist. 对脚的日常护理, 比如修剪指甲, 玉米的处理, bunions (except capsular or bone surgery therefor) and calluses is excluded.

Covered minor surgery includes surgery for ingrown nails and surgery in connection with the treatment of flat feet, 堕落的拱门, 弱的脚, chronic foot strain or symptomatic complaints of the feet.

Benefits for major surgical procedures rendered by a licensed podiatrist are not provided, except of surgery is rendered in a hospital.

第三条, 部分(10)(A) 25, of the 雇主’s Plan provides as follows:

(10) 一般除外责任:

25. Any type of services, supplies or treatments not specifically provided by the Plan.

讨论

第三条, Section A(3)(n) of the 雇主’s Plan provides benefits for minor surgery rendered by a qualified licensed podiatrist. Such services were covered by the Insurance Carrier. 然而, under this Podiatrists’ Services provision of the Plan, there is no reference made to the allowable coverage for podiatrists who assist in surgery. Benefits for assisting a surgeon under 第三条, Section A(3)(b) are only provided for surgery provided on an inpatient basis. The procedure in this case was provided on an outpatient basis. Consequently, it is not a covered service.

第三条, 部分(10)(A) 25, 说明任何类型的服务, supplies or treatments not specifically provided by the Plan are excluded from coverage. 因此, because assistant podiatrist’s services are not specifically provided by the Plan, such services are excluded from coverage.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for coverage of the assistant podiatrist’s fee.