| Petitioner: |
Respondent: |
| XXXXXXXXXXXXX |
Blue Cross and Blue Shield of Michigan |
Issued and entered December 19, 2002 by Frank M. Fitzgerald, Commissioner
ORDER
I
PROCEDURAL BACKGROUND
On November 25, 2002 the Petitioner, XXXXXXXX filed a request for external
review with the Commissioner of Financial and Insurance Services (Commissioner)
under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL
550.1929. After a review of the material submitted, the Commissioner accepted
the request on December 4, 2002.
The issue involved in the adverse determination is contractual.
The Commissioner reviews contractual issues pursuant to MCL 550.1911(7).
Because this matter does not involve the resolution of medical questions,
review by an independent review organization is not required. The Commissioner
notified Blue Cross and Blue Shield of Michigan (BCBSM) of the Petitioner’s
filing and requested the information it used in making its adverse determination.
The information was received December 13, 2002.
II
FACTUAL BACKGROUND
On June 17, 2002, the Petitioner went to a walk-in clinic
for eye discomfort. She was treated by Dr. XXXXXXXXXXX, M.D., who prescribed
eye drops. The doctor also recommended Petitioner see an eye doctor if
there was no improvement within 24 to 48 hours. Petitioner’s pain continued.
She contacted her optometrist, Dr. XXXXXXXXXX, O.D. who treated on June
18, 19, and 20, 2002. Dr. XXXXXX charged $150.00 for this care.
BCBSM denied payment for Dr.XXXXXXX services because Dr.
XXXXXX is an optometrist. BCBSM states that treatment by an optometrist
is not a benefit provided under Petitioner’s certificate of coverage.
Petitioner argues that since she lives in a rural area
in the XXXXXXXXXX she should not be punished for going to an O.D. under
these circumstances. She believes that since she followed the advise of
a medical doctor to see an eye doctor and this care was medically necessary,
BCBSM is required to pay for her care from Dr.XXXXXXX.
III
ISSUE
Is BCBSM required to pay for the care provided by Petitioner’s
optometrist on June 18, 19 and 20, 2002?
IV
ANALYSIS
Petitioner has coverage through XXXXXXXXXXXX, an industry
rated account. The Community Blue Group Benefit Certificate governs her
coverage. Under the certificate, physician services are a covered benefit.
Section 7 of the Certificate defines physician as a doctor of medicine,
osteopathy, podiatry, chiropractic, or dentistry.
Dr. XXXXXX is an optometric doctor or optometrist. This
does not meet the definition of physician as set forth in the Certificate.
The Petitioner failed to establish she could not have seen an eye doctor
that met the definition of physician. She did not argue there were no
physician eye doctors in her area. Therefore, the Commissioner concludes
the care provided by Dr. XXXXXX is not a covered benefit under the Certificate.
V
ORDER
The September 26, 2002 final adverse determination of BCBSM
is upheld. BCBSM is not required to pay for Petitioner’s treatment by
Dr. XXXXXXXXXX O.D. on June 18, 19, and 20, 2002.
This is a final decision of an administrative agency. Under
MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, 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.
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