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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-592 – August 26, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, Trustee.
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 influenza vaccinations under the terms of the Employer Benefit Plan.
Background Facts
On December 21, 1991 the Employee’s spouse sought treatment at her physician’s office due to an upper respiratory infection. During this visit, the Employee’s spouse was administered an influenza vaccination. The Employer provided benefits for the office visit, but denied benefits for the influenza shot on the grounds that it was not a covered service.
Dispute
Is the Employer required to provide benefits for the influenza vaccination administered to the Employee’s spouse on December 21, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the influenza vaccination administered to the Employee’s spouse on December 21, 1991 because immunizations are a covered benefit under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the influenza vaccination administered to the Employee’s spouse on December 21, 1991 because the immunization was not medically necessary.
Pertinent Provisions
Article III – Benefits
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. 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 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, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III. A. (3)(o) 2. of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(o) Primary Medical Care – Miscellaneous
2. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness, deafness, and other screening and diagnostic procedures when medically necessary.
Discussion
The Introduction to Article III states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care. The Introduction further states that the fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (3)(o) 2. of the Employer Benefit Plan provides benefits for many preventive health measures, including immunizations, along with pap smears, examination for cancer, blindness and deafness, as well as other screening and diagnostic procedures when medically necessary.
In ROD 88-371 (enclosed herein) the Trustees decided that immunizations administered consistent with standards of medical practice for routine prophylactic vaccinations qualified for benefits under the Employer Benefit Plan. ROD 88-371 also notes that medical necessity is not necessarily construed to imply imminent danger or the actual onset of disease or illness, such as the administration of rabies vaccine after a wild animal bite, but also refers to the application of prudent medical practice and preventive care, as in the case of screening for hypertension and diabetes. This would also include the administration of tetanus, diphtheria or measles, mumps and rubella (MMR) vaccinations.
In this case, the Employee’s spouse was administered an influenza vaccination. Since this vaccination was issued under a physician’s care and is not inconsistent with accepted medical standards and prudent medical practice, the Trustees conclude that the medical necessity requirement of the Introduction to Article III and Article III. A. (3)(o) 2. is met, and consequently, the influenza vaccination is eligible under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for the influenza vaccination administered to the Employee’s spouse on December 21, 1991.