Opinion ID: 777312
Heading Depth: 2
Heading Rank: 2

Heading: Oxford's Coverage of Care for Mr. Fay

Text: 12 In 1996 and 1997, Oxford provided to Mr. Fay coverage for 24-hour private duty nursing care, under the Plan's Home Health Care and Skilled Nursing Facility provisions. Both items of coverage had annual limits: (1) the home health benefit provided 200 visits, of 4 hours each, per year (33 days of 24-hour per day care); and (2) the SNF benefit provided 200 days of coverage in such a facility. For 1996 and 1997, Oxford agreed to convert the 200 SNF days to cover Mr. Fay's home care provided that his condition continue[d] to meet the criteria for Home Care, giving a total of 233 days of private duty coverage. Oxford informed the Fays, however, that when the Fays exhausted these benefits, Oxford would no longer cover full-time, in-home care for the remainder of the year. In 1996, Mt. Sinai agreed to cover the remainder of the days, as an interim solution and an exception to [the] contract provisions. In a letter to Mrs. Fay, Mt. Sinai advised that Mount Sinai will not extend the extra contractual benefits into 1997 and that Mrs. Fay should pursue other coverage and funding options. 13 As warned, Oxford notified the Fays that coverage for home nursing services would cease on August 21, 1997, and that they should inquire as to other funding options. Oxford enclosed with its notification letter a list of federal and state agencies from which the Fays might seek additional funds. In 1998, Oxford did not approve the Fays' request for home care benefits, claiming that such coverage was neither covered by the Plan nor medically necessary, as that term is used in the Plan. While Oxford approved the 200 home care visits (33 days of 24-hour per day coverage) for 1998, it refused to convert the 200 SNF days as it had in 1996 and 1997. No home nursing care benefits have been paid since that time.