Issued and entered October 28, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On September 30, 2002, Petitioner XXXXXX XXXXX filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. After an assessment of the material submitted, the Commissioner accepted the request.

The issue involved is contractual in nature. There is no medical issue; therefore, review by an Independent Review Organization is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On October 17, 2002, the Office of Financial and Insurance Services (OFIS) received from Physicians Health Plan of Mid-Michigan (PHPMM) the information it used to make its final adverse determinations in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a PHPMM member, covered under the PHPMM Certificate of Coverage. She suffers from foot deformities and from arthritis in her hands. Petitioner is seeking coverage for orthotics and Jobst compression gloves prescribed by her doctors.

PHPMM received a letter from Petitioner, dated July 5, 2002, requesting coverage for orthotics and compression gloves. Because these items are not covered benefits under the Petitioner’s Certificate of Coverage, PHPMM treated the letter as her initiation of the internal grievance process. PHPMM issued its final adverse determinations concerning the orthotics and the compression gloves on August 5, 2002.

III
ISSUES

A. Whether PHPMM properly denied Petitioner coverage for orthotics?
B. Whether PHPMM properly denied Petitioner coverage for compression gloves?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues PHPMM should pay for the orthotics and compression gloves because her doctors prescribed them and she needs them to manage her foot problems and the arthritis.

PHPMM’S ARGUMENT

In its letter dated October 17, 2002, PHPMM submitted its arguments in this case to OFIS. The letter states:
COMPRESSION GLOVES ARE EXCLUDED FROM COVERAGE UNDER [PETITIONER’S] BENEFIT CONTRACT.

[Petitioner’s] benefit contract excludes coverage for compression gloves in Section 11.1W…which states no coverage exists for:

“…outpatient prescribed or non-prescribed medical supplies including, but not limited to, elastic stockings…and like products”.

A compression glove is the same thing as an elastic sock, only for use on the hand rather than the foot.

PHPMM also received approval from OFIS on April 4, 2002 of an amendment that even more directly excludes coverage for the compression gloves. The amendment…states that Section 11.1W was modified and replaced with the following language:

“Outpatient prescribed or non-prescribed medical supplies including but not limited to elastic stockings, TEDS stockings, JOBST stockings…and like products.”

The amendment was provided to all members and [sic] upon renewal. [Petitioner’s employer] renews on July 1, so [Petitioner] would have received the amendment twice: once as part of a mass mailing and once with the renewal package. The amendment clearly states that JOBST stockings and like products are excluded from coverage.

* * *

ORTHOTICS ARE AN EXPRESS EXCLUSION UNDER [PETITIONER’S] BENEFIT CONTRACT.

[Petitioner’s] benefit contract specifically excludes coverage for orthotics. Section 11.10 of the HMO certificate…provides:

“Orthotic appliances (including shoe orthotics) are excluded.”

There is no ambiguity in the terms of the exclusion.

CONCLUSION

PHPMM has properly denied coverage for compression gloves and orthotics. In accordance with the approved provisions of the benefit contract and the even more specific terms of the April 2002 amendment, compression gloves are excluded as medical supply. The orthotics are expressly excluded as an “orthotic appliance (including shoe orthotics)” in the benefit contract. As the terms are both unambiguous and prior approved, PHPMM believes that OFIS should apply general rules of contract construction and should affirm PHPMM’s denial of coverage for both items.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents submitted by the parties. The focus of this analysis is whether Petitioner has coverage for compression gloves or orthotics under her Certificate of Coverage. Section 11.1(O) of the Certificate clearly excludes orthotics from coverage. Because orthotics is not a covered benefit under her Certificate of Coverage, PHPMM properly denied Petitioner coverage for orthotics.

The Certificate also excludes compression gloves in Section 11.1(W). It does not exclude compression gloves by name, but the Certificate language is clear. Section 11.1(W) excludes prescribed medical supplies, and specifically excludes “elastic stockings…and like products.” The Commissioner agrees with PHPMM’s finding that compression gloves are a medical supply similar to elastic stockings and are excluded from coverage. Accordingly, the Commissioner finds PHPMM’s final adverse determinations on these issues, regarding orthotics and compression gloves, are valid.

V
ORDER

Therefore, it is ORDERED that PHPMM’s August 5, 2002, final adverse determinations in this case are upheld. PHPMM is not required to cover orthotics or compression gloves for Petitioner.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.