Issued and entered April 10, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On March 6, 2003, XXXXXXXXXXXXX (“Petitioner”), 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 et seq. The Commissioner’s staff assessed the material submitted by the Petitioner and accepted the request.

The issue involved is contractual in nature and not a medical issue. Therefore, review by an Independent Review Organization (IRO) is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On March 14, 2003, the Office of Financial and Insurance Services received from US Health and Life Insurance Company (USHL) the information it used in making its adverse determination.

II
FACTUAL BACKGROUND

Petitioner’s son, was born with Esophageal Atresia. This condition prevented the child from obtaining nutrition from a bottle or breast-feeding. The child had a G-tube inserted, which provided an avenue to receive daily nutrition. At the age of one, the child was switched from Similac and breast-milk to Pediasure. Petitioner is seeking coverage for the Pediasure.

USHL denied Petitioner’s claim stating its policy does not cover nutritional supplements.

III
ISSUE

Whether USHL complied with the terms of its Certificate of Insurance when it denied Petitioner coverage for Pediasure?

IV
ANALYSIS

Petitioner’s Argument

Petitioner’s infant son was born with Esophageal Atresia. A G-tube was inserted within 24 hours of birth, which enabled the child to receive nutrition from Similac and breast-milk. Since birth, the child has undergone numerous surgeries in hopes of correcting the defect. At the age of one, the child was placed on Pediasure as the only source of nutrition. Petitioner states progress is being made to correct this defect, however, the child has developed other resistance and sensitivity around the mouth and must continue Pediasure through his G-tube as the source of his nutritional diet. Petitioner provided supportive documentation from the child’s physician detailing the child’s condition.

On XXXXXXXXX, XXXXXXXXXXXXXXXXXX (provider of the child’s home enteral therapy) submitted an appeal on behalf of Petitioner for the cost of the Pediasure. USHL denied the claim stating the plan excludes nutritional supplements. Petitioner argues that Pediasure was not a nutritional supplement in his son’s case. It is the primary source of nutrition.

US Health and Life Insurance Company Argument

On February 10, 2003, USHL issued its final adverse determination. USHL denied coverage for the Pediasure based on a contractual provision. USHL states the plan specifically excludes nutritional supplements. The certificates states in part:

7.4 “General Exclusions” The calculation of benefits payable under this Policy shall not include or be based upon any charge made for or in connection with any Hospital Confinement, or any examination, or any surgical, medical or other treatment, or any service or supply:

45. for vitamins or nutritional supplements, unless obtained through prescription and not available without such prescription; or

USHL argues that although the nutritional supplement Pediasure was prescribed, it is an over the counter item that does not require a prescription, therefore falls under the above exclusion.

Commissioner’s Review

The Commissioner carefully reviewed the documents submitted and the positions of the parties. The Commissioner empathizes with the Petitioner and is sensitive to the request. However, the Certificate of Coverage is clear. Nutritional supplements are not covered unless obtained by a prescription and not available without such prescription [emphasis added]. Pediasure is available without a prescription.

Based on the documentation presented, the Commissioner therefore finds USHL denied Petitioner’s claim for reimbursement for Pediasure according to the terms of the certificate of insurance.

V
ORDER

It is Ordered that the final adverse determination of US Health and Life Insurance Company is upheld. USHL is not required to cover the expense for the Pediasure requested by the 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.