Issued and entered December 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 12, 2002, XXXXXXXXXXXXXX on behalf of her husband XXXXXX XXXXXXX (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, (PRIRA) MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request.

There is no medical issue; therefore, review by an Independent Review Organization (IRO) is not required. The issue involved is contractual in nature. The Commissioner reviews contractual issues under MCL 550.1911(7). On August 28, 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 determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a PHPMM member, covered under the PHP Certificate of Coverage. He suffered a stroke on March 19, 2002, resulting in moderate-to-severe expressive aphasia and moderate receptive aphasia. He underwent inpatient rehabilitation therapy, including physical, occupational, and speech therapy, immediately following the stroke. Petitioner continued speech therapy on an outpatient basis from April 4, 2002 to July 19, 2002. During that time, his function progressed to moderate expressive aphasia and mild receptive aphasia. He stopped speech therapy after July 19, 2002, because had received the maximum allowable benefits for rehabilitation services for one year according to the PHP Certificate of Coverage.

It is very likely that Petitioner would continue to progress in his expressive and receptive functions with further speech therapy. He still has poor verbal expression, reading and writing difficulties, and decreased concentration and impulse control. His speech therapists believe treatment could restore high verbal and auditory comprehension skills and basic reading and writing skills, with the possibility of improving his overall function to the point that Petitioner could return to work.

Petitioner initiated PHPMM’s internal grievance process on July 12, 2002, in anticipation of reaching the end of his benefits for rehabilitation therapy. He requested that PHPMM extend his coverage to include all necessary recommended speech therapy in the future. PHPMM reached a final adverse determination in Petitioner’s case on August 5, 2002.

III
ISSUE

Did PHPMM properly deny Petitioner coverage for speech therapy in excess of the maximum allowable benefits for rehabilitation therapy in the PHP Certificate of Coverage?

IV
ANALYSIS

Petitioner’s Position

Petitioner claims PHPMM should continue to provide him with coverage for speech therapy, because it is medically necessary for his recovery from a stroke. He points out that he still has a lot to gain from speech therapy, and he and his wife cannot afford to pay for it. Therefore, PHPMM’s final adverse determination in this matter should be reversed.

PHPMM’S Position

In its August 26, 2002 letter to OFIS, PHPMM states:

PHPMM’s Certificate of Coverage excludes coverage for Outpatient Rehabilitation Services in Section 12…which states:

“Outpatient Rehabilitation Services (Physical therapy, occupational therapy, speech therapy, and cardiac/ pulmonary rehabilitation.)

$0 per visit [co-pay] Limited to 60 visits per calendar year of any combination of therapies”

…the enrollee has exhausted the 60-visit maximum for Speech Therapy. PHPMM has correctly administered the benefits contained in the Certificate of Coverage as previously approved by OFIS. Coverage for speech therapy is expressly limited within Section 12 of the enrollee’s HMO benefit contract…. PHPMM believes, therefore, that OFIS should uphold PHPMM’s adverse determination pursuant to the express terms of the benefit contract.

Commissioner’s Review

The Commissioner carefully reviewed the positions and documents presented by the parties. The focus of this analysis is whether the PHP Certificate of Coverage that controls Petitioner’s health benefits allows for coverage of speech therapy in excess of the maximum allowable benefits for rehabilitation therapy. It clearly does not. The Schedule of Benefits set forth in Section 12 of the PHP Certificate of Coverage plainly and unambiguously states that benefits for rehabilitation services, including speech therapy, are limited to 60 visits per calendar year. Subsection 10.20 Outpatient Rehabilitative Services of the PHP Certificate states that short-term outpatient rehabilitation services are a covered benefit subject to the limitations in the Schedule of Benefits set forth in Section 6..

Although the Commissioner has great empathy for Petitioner and his family, it is the provisions contained in the PHP Certificate of Coverage that govern this coverage analysis. Petitioner has exhausted the total benefits for speech therapy in the Certificate for the calendar year 2002. Accordingly, the Commissioner finds that PHPMM’s final adverse determination in this matter is valid.

V
ORDER

Therefore, the Commissioner ORDERS that PHPMM’s August 5, 2002, final adverse determination in this case is upheld. PHPMM is not required to provide Petitioner with coverage for speech therapy in excess of the maximum benefit of 60 visits allowed for rehabilitation therapy in the PHP Certificate of Coverage.

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.