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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-223 – January 24, 1990
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.
根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了有关根据雇主福利计划条款提供心理评估和治疗健康福利的争议的事实和情况.
Background Facts
雇员的律师建议雇员在自愿的基础上从临床心理学家那里获得心理评估，作为雇员对刑事起诉的辩护的一部分. The Employee was evaluated by a clinical psychologist on July 6, 1989 and underwent individual psychotherapy sessions on September 16 and 30, 1989 and October 4, 14 and 21, 1989. 雇主的保险公司在9月27日的信函中通知了雇员, 1989年说，它拒绝给心理评估和个人心理治疗会议带来好处，因为这些评估在医学上既不是必要的，也不是由医生下令的. 雇员的医生在10月16日给临床心理学家写了一封信, 1989, referring the Employee for “medical care and treatment.”
Dispute
雇主是否需要为员工的心理评估和个人心理治疗提供福利?
Positions of the Parties
雇员的职位:雇主必须为雇员的心理评估和个人心理治疗提供健康福利.
雇主的立场:雇主不需要为雇员的心理评估和个人心理治疗提供健康福利，因为这些评估既不是医学上必需的，也不是由医生下令进行的.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
ARTICLE III–BENEFITS
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.
Article III. A. (7)(f) of the Employer Benefit Plan states:
(7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for:
Psychotherapy, psychological testing, counseling, 团体治疗和酗酒或药物康复方案，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.
3. School related behavioral problems.
4. Services by private teachers.
5. 酗酒和戒毒康复，如果康复小组事先没有确定受益人是康复的良好候选人.
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
Discussion
According to the Introduction to Article III of the Employer Benefit Plan, 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. 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. 导言进一步指出，不合理和不必要的服务应包括未经医生命令的程序. Under Article III. A. (7) (f) of the plan, benefits are provided for psychotherapy, psychological testing, counseling, 在没有免费护理资源和医生确定有医疗需要的情况下，进行团体治疗和酗酒或戒毒康复方案.
In this case, 雇员的律师建议雇员自愿接受临床心理学家的心理评估. The evaluation was performed on July 6, 1989, 该员工于9月16日开始与临床心理学家进行个人心理治疗, 1989. 雇主以这些服务不是由医生安排的为由拒绝提供福利, 雇员的医生给临床心理学家写了一封信，推荐雇员接受医疗照顾和治疗. However, 该信没有具体说明雇员被转介接受的治疗类型，也没有说明为什么这种治疗在医学上是必要的. 因为在本案中进行心理测试和心理治疗的医学必要性尚未确定, as required under Article III. A. (7)(f)雇主不需要为这些服务提供福利.
Opinion of the Trustees
在这种情况下，雇主不需要为雇员的心理评估和个人心理治疗提供健康福利.