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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: 81-674——1986年1月28日
Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 the provision of health benefits for biofeedback therapy under the terms of the 雇主 Benefit Plan.
背景事实
The 员工 has been treated for anxiety neurosis on an inpatient as well as an outpatient basis. He was hospitalized from May 21, 1984 through May 25, 1984 for this condition. 出院的时候, his attending physician “recommended and planned” that the 员工 undergo biofeedback therapy “as an integral part of his treatment.” The 雇主 has denied payment for this service under the provisions of Q&A 81-42(附在这里).
争端
Is the 雇主 responsible for payment of charges for biofeedback therapy as part of the treatment of the 员工’s anxiety neurosis?
双方立场
Position of the 原告: The Complainant contends that this therapy should be considered a covered benefit for treatment of his anxiety neurosis.
Position of the 被申请人: The Respondent contends that the charges for the 员工’s biofeedback therapy were properly denied in accordance with the provisions of Q&A 81-42.
相关的规定
Article III A (11) (a) 24 of the 雇主 Benefit Plan provides:
(a) In addition to the specific exclusions otherwise contained in this plan, benefits are also not provided for the following:
24. Charges for treatment with new technological medical devices and therapy which are experimental in nature.
Q&A – 81-42 (Revised September 3983).
引用: Amended 1950 and 1974 Benefit Plans and Trusts Article III A (7) (f) and A (11) 24.
问题: Are benefits provided for biofeedback therapy?
答: Biofeedback therapy is generally a non-covered benefit. 可能会涉及生物反馈, 然而, when prescribed by a physician, and when it is reasonable and necessary for an individual patient for muscle re-education of specific muscle groups for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness and only when more conventional treatments (such as heat, 冷, 按摩, 锻炼, support) have been attempted and have not been successful.
付款 for biofeedback therapy, when covered, will be made only to aphysician, clinic or hospital.
讨论
Under Article III A (11) (a) 24 of the 雇主 Benefit Plan, charges for treatment with new technological medical devices and therapy which is experimental in nature are excluded from coverage. 根据Q&A 81-42 biofeedback therapy is generally a non-covered benefit except when certain criteria have been satisfied. 这个问&A is consistent with 医疗保险’s current coverage guidelines for this therapy.
A Funds’ consultant has reviewed the available information regarding the 员工’s biofeedback therapy and has determined that the criteria for coverage established in Q&A 81-42 have not been satisfied. The use of biofeedback therapy for the treatment of the 员工’s anxiety neurosis does not fall within the specific clinical categories for which biofeedback therapy may be considered a covered benefit under the provisions of Q&A 81-42. The 雇主 therefore is not responsible for payment of the charges relative to the 员工’s biofeedback therapy.
受托人的意见
The 雇主 is not responsible for providing benefits for the 员工’s biofeedback therapy used to treat his anxiety neurosis.