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.