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

ORDER

I
PROCEDURAL BACKGROUND

On June 17, 2002, Petitioner XXXXXXXXXXX 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 et seq. 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 (IRO) is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On June 26, 2002, the Office of Financial and Insurance Services (OFIS) received from Blue Care Network of Michigan (BCN) the information it used to make its adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a BCN member. He seeks coverage for compression stockings to manage severe venous insufficiency problems in his left leg. BCN denied Petitioner coverage for compression stockings, because elastic stockings are an excluded benefit under his BCN 5 Certificate of Coverage. Petitioner exhausted BCN’s internal grievance procedures, and BCN issued a final adverse determination in this matter on May 28, 2002.

III
ISSUE

Did BCN properly deny Petitioner coverage for compression stockings?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues BCN should provide him with coverage for compression stockings, because they are medically necessary to treat his severe venous insufficiency problems. Petitioner claims someone from BCN’s customer service department told him that BCN would pay for compression stockings, if he proved they were medically necessary. Statements from his doctors clearly establish medical necessity. Therefore, the Commissioner should reverse BCN’s final adverse determination in this matter.

BCN’S ARGUMENT

In its May 28, 2002, final adverse determination letter to Petitioner, BCN argues:

…[BCN] does not dispute the stockings are medically necessary for treatment of [Petitioner’s] condition, however, they are not covered under the benefit package purchased by [Petitioner’s] employer. Therefore, [Petitioner’s] request for the stockings remains denied.

Please see the…BCN 5 Schedule of Benefits, section 1.15, page 10, Exclusions, which states, “Durable Medical Equipment: Exclusions: Disposable supplies such as sheets, bags, or elastic stockings.”

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents submitted by the parties. The focus of this analysis is whether BCN properly denied Petitioner coverage for compression stockings, according to the BCN 5 Certificate of Coverage. The Certificate includes the BCN 5 Your Benefits booklet. Section 1.15 of Your Benefits (referenced above in BCN’s Argument as Section 1.15 of the BCN 5 Schedule of Benefits) clearly and unambiguously states that elastic stockings are not a covered benefit. Furthermore, the Certificate contains no provision stating that elastic stockings become a covered benefit if they are medically necessary. Because the BCN 5 Certificate of Coverage gives Petitioner plain and obvious notice that compression stockings are not eligible for coverage, the Commissioner finds BCN’s final adverse determination in this matter is valid.

IV
ORDER

The Commissioner ORDERS that BCN’s May 28, 2002, final adverse determination in Petitioner’s case is upheld. BCN properly denied Petitioner coverage for compression stockings.

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.