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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: 84-602——1988年6月7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 benefits for chiropractic services under the terms of the 雇主 Benefit Plan.

背景事实

雇员的配偶, 犹他州的居民, received treatment by a chiropractor from December 3, 1987 through December 15, 1987. The 雇主 stated that, although the services of chiropractors are excluded under the 雇主 Benefit Plan, it provides coverage for them at the reasonable and customary rate because state law in Utah requires that Utah-based insurance companies recognize licensed chiropractors as medical providers. The 雇主 says it provided health benefits coverage at the reasonable and customary rate for the 员工 “s spouse’s radiology and laboratory tests and office visits (excluding copayment charges). 它拒绝支付70美元.收费的1000元, which it considered to be excessive, because it is not required to pay for charges above the reasonable and customary rate under the 雇主 Benefit Plan. The 员工 asks whether the 雇主 is responsible for payment of the outstanding balance of $70.00 for chiropractic services.

争端

Is the 雇主 responsible for payment of the outstanding charge for chiropractic services?

Positions of the Parties

Position of the 员工: The 雇主 is responsible for payment of the outstanding charge for the 员工’s spouse’s chiropractic services.

Position of the 雇主: Even though the 雇主 has been paying reasonable and customary charges for chiropractic services above and beyond the provisions of the 雇主 Benefit Plan, the 雇主 is not required to hold the 员工 harmless for non-covered services.

相关的规定

第三条. A. (3) (p) 1. of the 雇主 Benefit Plan states:

(p) 未涵盖的服务

1. Services rendered by a chiropractor or naturopathic services.

讨论

第三条. A. (3)(p) 1. of the 雇主 Benefit Plan states that services rendered by a chiropractor are specifically excluded from coverage. The 雇主 has been paying the usual and customary rate for chiropractic services because, 根据犹他州法律, Utah-based insurance carriers are required to recognize licensed chiropractors as medical providers and to provide health benefits coverage for their services. 根据第三条A款. (10) (g) 2., an 员工 may be liable for any services of the provider which are not provided under the Plan. Chiropractic services are not provided under the Plan.

Opinion of the Trustees

The 雇主 is not responsible for payment of the outstanding charge for the 员工’s spouse’s non-covered services.