____________________________________________________________________________
OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
受托人:
在再保险
员工
雇主
98-023 - 2003年4月16日
A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D. 哈德森和艾略特A. 西格尔.
受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.
背景事实
投诉人的儿子, whose date of birth is September 31, 1983, was admitted to a residential long-term treatment facility affiliated with a 孩子们的 hospital from February 2, 1999, 至四月二十三日, 1999. 的 facility is approved by the Joint Commission on Accreditation of Hospitals. 的
admitting diagnoses were attention deficit disorder, neurotic depression and oppositional disorder.
According to the Respondent, the services provided by the facility are not covered based on plan provisions. 然而, 在审查索赔后, the Respondent noted that on February 3, 1999, 治疗机构的一名代表就住院治疗方案的预授权问题联系了被告的保险公司. But due to staffing changes since February 1999, 保险公司无法确认是否在2月3日讨论了该设施的许可证或提供的治疗类型, 1999. 因此, 作为一种善意的行为, the Respondent stated that it provided coverage for all services except for the following: 1) private tutors; 2) 行为疗法; and 3) room and board when the patient was on leave from the facility (the Complainant’s son went home for visits on weekends).
Based on information provided, 活动疗法是由国家认证的治疗专家提供的，这些专家是由国家许可的，他们是包括精神科医生在内的治疗团队的一部分, 社会工作者, psychologists and other professionals.
争端
被投诉人是否需要为投诉人儿子从2月2日起的剩余医疗费用提供保险, 1999, 至四月二十三日, 1999?
Opinion of Trustees ROD Case No. 第2页
双方立场
投诉人的立场:被投诉人必须支付投诉人儿子的剩余医疗费用，因为所提供的所有服务都是其儿子治疗的必要组成部分.
被投诉人的立场:被投诉人不需要为投诉人儿子的剩余医疗费用提供保险，因为私人教师的保险, 行为疗法, and charges for room and board when the patient is not present are not covered under the 雇主 Benefit Plan.
相关的条款
的 Introduction to Article III of the 雇主 Benefit Plan 状态:
第三条-福利
承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内. In determining questions of reasonableness and necessity, 将适当考虑提供服务的社区医生的习惯做法. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, 因此，本款不得被解释为减损本条款III所述的计划覆盖范围或资格.
第三条A. (1) (a) states in pertinent part: A. 健康的好处
(1) Inpatient Hospital Benefits (a) Semi-private room
Opinion of Trustees ROD Case No. 第3页
第三条A. (7) (f)规定:
A. 健康的好处
When a Beneficiary is admitted by a licensed physician (hereinafter
“physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), 补助金将用于半私人房间住宿(包括特殊饮食和一般护理)以及医院为诊断和治疗受益人的病情而提供的下述所有医疗必要服务.
***
的决心
(7)其他福利
(f) Outpatient Mental Health, Alcoholism and Drug Addiction Benefits are provided for:
心理治疗, 心理测试, 咨询, 团体治疗和酗酒或戒毒方案，在没有免费护理来源的情况下，当医生确定有医疗需要时.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental deficiencies.
has not been made by the 康复 team that the Beneficiary
Opinion of Trustees ROD Case No. 第4页
is a good candidate for 康复.
6. Alcoholism and drug 康复 programs not approved by
医疗保险. 第三条A. (11) (a) 27. 状态:
A.
健康的好处
(11)
一般的除外
在以下:
(a)
In addition to the specific exclusions otherwise contained the Plan, benefits are also not provided for the
27. Any types of services, supplies or treatments not specifically provided by the Plan.
讨论
《皇冠搏彩中心网站》第三条导言指出，所涵盖的服务仅限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 《官方网站》进一步指出，医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不包括在本计划之内.
申诉人的儿子被送进一所住院治疗设施接受精神疾病的长期治疗. 的 Respondent provided coverage for all services except for the following: 1) private tutor; 2) 行为疗法; and 3) room and board when the beneficiary was not in attendance.
Concerning coverage for a private tutor, 第三条A. (11) (a) 27 states that any service not specifically provided by the terms of the Plan is excluded from coverage. 的 medical portion of the Plan contains no provision that provides coverage for a private tutor. 事实上, 根据第三条a款，私人教师提供的服务是门诊心理健康福利的一种不包括在内的福利. (7)(f) 4.
Concerning the second issue listed above, 行为疗法, 雇主福利计划提供精神疾病的住院治疗，但不排除任何具体服务. 见ROD 88-788. 医疗保险和皇冠搏彩中心网站将涵盖活动治疗，如果它是在一个结构化的治疗方案中使用，但不包括其目的是纯粹的娱乐. 在这种情况下，活动疗法与一个人的残疾精神健康问题的护理和治疗有关.
Opinion of Trustees ROD Case No. 第5页
Because the 行为疗法 in this case was part of a structured treatment program, the therapy is covered under the 雇主 Benefit Plan.
Finally, in cases concerning room and board for hospital stays, the Funds follows 医疗保险 policy. 精神病学, 康复, 孩子们的, and other specialty hospitals are paid a per diem rate for the days the patient is in the facility. 然而, 医疗保险 does not cover days for which the patient is on leave of absence. 在这种情况下, the facility is a 孩子们的 psychiatric hospital; therefore, days for which a patient is on leave would not be covered under 医疗保险 or the Funds.
受托人的意见
Under the terms of the 雇主 Benefit Plan, 投诉人的儿子在工厂休假期间，投诉人不需要为私人教师或食宿提供保险. 的 Respondent is required to provide coverage for 行为疗法.