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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 1984年3月26日

Board of Trustees: Harrison Combs, Chairman; John J. 奥康奈尔，受托人. 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 payment for the reversal of a tubal ligation. 他们在此就此事发表意见，

背景事实

2月10日, 1982, 员工’s spouse underwent a tubal reanastomosis or the reversal of a sterilization procedure, 在其征求咨询意见的请求中, 雇员声称其配偶于一月二十一日及二十五日致电雇主, 及二月九日, 1982, 核实雇主福利计划下程序的覆盖范围. The 员工 also submitted a statement from the surgeon’s bookkeeper indicating that she contacted the 雇主 twice on January 22, 1982, 以核实配偶的保险范围.还提交了1月22日簿记员的电话记录副本, 1982, 显示病人的身份信息, 输卵管再吻合术的程序描述, 在“预先确定津贴”的标题下,并表明该患者“被覆盖至2月第三周”,”

在回应, 雇主声明:, although its 索赔 examiners verified 员工’s spouse’s eligibility under its Plan, 从来没有明示或暗示过, 证实或暗示输卵管吻合术是其计划所涵盖的服务. On this basis, it denied payment for the charges incurred as a result of the surgery.

作为他们对这场纠纷调查的一部分, 受托人的一名工作人员会见了雇员及其配偶, the 雇主’s Plan Administrator and 计划管理员’s 员工 with whom 配偶 spoke. 据配偶说, 她在1月21日打电话给计划管理员办公室, 1982, because her husband was then on lay-off: She was uncertain whether he would have continued coverage at the time of her operation, and her physician required that she have insurance coverage before he would perform the surgery. The spouse thought she may have referred to the procedure during that conversation, 但他对此并不确定，也没有谈话记录. 医生再次询问雇员是否有保险, 雇员于1月22日致电计划管理人, 1982, 并被告知他将继续报道直到1982年7月. 配偶在1月25日和2月9日再次联系了计划管理人, 1982, 确认她有保险, 但没有这些通话记录. The 员工 also provided the Trustees with a copy of a claim for a visit to the physician that was paid by the Respondent. The claim was submitted to 计划管理员 on February 3, 1982, and paid on February 25, 1982.

The Plan Administrator stated that its claims examiners answer beneficiaries’ questions concerning their periods of benefits coverage eligibility but are not authorized to grant prior authorization for coverage of specific services, Requests for prior authorization are referred to its Manager of Health Services or its Director of Workers’ Compensation and Medical Benefits, 事先授权只能以书面形式提供. The Plan Administrator has no record that it granted prior authorization for 配偶’s surgery. The Plan Administrator does not require its claims examiners to keep notes of telephone inquiries verifying coverage.

The Plan Administrator’s claims examiner with whom 配偶 spoke stated emphatically that 配偶 had not asked her whether the specific procedure would be covered. The claims examiner did not recall speaking with 员工 or with the physician’s bookkeeper.

根据他对上述个人的采访, the Trustees’ staff member concluded that the purpose of the calls to the plan administrator by 配偶, 员工, and the physician’s bookkeeper was to verify 配偶’s eligibility for benefits coverage, 不要求事先批准手术. The staff member also concluded that neither 计划管理员 nor any of its employees granted prior authorization far the surgery.

争端

Is the 雇主 responsible for payment of the charges resulting from 员工’s spouse’s tubal reanastomosis on February 10, 1982?

双方立场

Position of 员工: The charges for the reversal of 员工’s spouse’s tubal ligation should be considered a covered benefit since a representative of the company authorized payment of the medical expenses resulting from this procedure,

Position of the 雇主; The charges resulting from 员工’s spouse’s elective reversal of a previous tubal ligation are not covered since Article A. (11) (a) 14 of the Benefit Plan specifically excludes charges for the reversal of sterilization procedures. 除了, the 雇主 denies that prior authorization was ever granted by 计划管理员 for coverage of the charges for this procedure.

相关的规定

第三条A. (11) (a) 14. 雇主的福利计划规定:

第三条-福利

A. 健康的好处

(11) 一般的除外

(a)除了《官方网站》中另有规定的具体除外事项之外, 以下情况也不提供福利:

14. 撤销消毒程序的费用.

讨论

根据第III A条第(11)(A)款. 雇主的福利计划, charges for the reversal of sterilization procedures are specifically excluded from cover’ age, 然而, 员工 and his spouse contend that prior authorization of this procedure was obtained from the company and, 因此, 这笔钱应该支付. The 员工 has not submitted any evidence that his spouse received prior authorization in writing. 和, 基于对员工的采访, 配偶, 计划管理员, 以及计划管理人的索赔审查员, 皇冠搏彩中心网站的工作人员得出结论, although 员工’s spouse and representatives of her treating physician’s office contacted the 雇主 to determine 员工’s spouse’s eligibility for health benefits coverage, the specific issue of authorization for the reversal of a tubal ligation had never been raised nor addressed. Only the fact that 员工’s spouse was eligible for health Benefits coverage was verified by the 雇主’s representative. 除了, at no time did the employer explicitly or implicitly verify that the Employe’s Spouse’s health benefits coverage would cover the tubal reanastomosis. 因此, as the procedure is specifically excluded from coverage under the provisions 雇主的福利计划, the 雇主 is not responsible for payment of 员工’s spouse’s tubal reanastomosis.

受托人的意见

The 雇主 is not responsible for the provision of benefits for the referral of 员工’s spouse’s sterilization procedure,