By Anthony Rice
In City of Chicago, the arbitrator found that a police officer was misled into believing her medical insurance covered her therapy. The arbitrator held that it is fundamentally unfair to put the onus on the employee to understand an incorrectly labeled doctor’s referral slip, and then reach the conclusion her treatment is not cover without a pre-certification.
Although the Grievant in this case was a City of Chicago police officer, she was a dependent on her husband’s, a fellow CPD officer, medical plan. In October 2008, following the birth of a son, the Grievant experienced numbness and tingling in her left hand. Her doctor—within the covered medical plan—diagnosed her symptoms as carpal tunnel syndrome and referred her for therapy. The referral form was entitled “Physical Therapy Referral.” However, the Grievant never received physical therapy; she received occupational therapy. Occupational therapy, under the City’s medical plan, is not covered without certain pre-certification requirements not met in this case
The union asserted they should prevail because, in addition to a referral that said “Physical Therapy,” neither the referring doctor nor the therapist ever informed the Grievant she was actually receiving occupational therapy. The City countered by showing that the Grievant was provided with a summary plan document, and open enrollment forms, that referenced the pre-certification requirements in a footnote.
The arbitrator weighed both side’s evidence and reached the following conclusion:
There is no evidence that Grievant was told by her doctor or the therapist that “pre-cert” might be required. There is the summary plan documents and the open enrollment forms that have footnotes referencing 42X and 43X and pre-certification requirements for occupational therapy (43X). But when balanced against the information on Joint Exhibit 15, the actual physician’s referral form, the possibility that Grievant was reasonably misled, as she claimed at the arbitration hearing, is too great to ignore, I hold
To put the onus of understanding the true nature of an incorrectly labeled referral slip based on medical codes no layman knows, is an unreasonable expectation, and that is how this case actually has played out, I rule. Fundamental fairness requires no less.
