____________________________________________________________________________

受托人的意见
____________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 11-0080 – 2014年9月24日

受托人: 迈克尔·H. Holland, Michael McKown, Daniel R. 杰克和马蒂·D. 哈德逊

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

The complainant’s spouse sought prior approval for a power wheelchair and lift recommended by her attending physician to assist her in daily activities. The patient suffered a stroke with left hemiparesis, a lumbar spine fracture and surgical fusion, and has high blood pressure, diabetes and chronic back pain with inability to walk unaided.

Respondent’s Third Party Administrator approved the power wheelchair and denied the lift as ineligible for coverage under the terms of the 雇主 Benefit Plan.

争端

Is Respondent required to provide benefits for Complainant’s spouse’s power lift?

双方立场

Position of the 原告: The lift was prescribed by the attending physician and is a medically necessary, covered benefit under the Plan.

Position of the 被申请人: Lifts are not covered under the terms of the 雇主 Benefit Plan and are not durable medical equipment as defined by the Plan.

相关的规定

第三条.A.(6)(d) of the 雇主 Benefit Plan states:

(6)家庭健康服务 & 设备

(d)医疗设备
Benefits are provided for rental or, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.

Q&A 81-38 states, in pertinent part:

Question: What medical equipment and supplies are covered under the Plan?

答:

A. Under the Home Health Services and 设备 provision, benefits are
provided for the rental and, 在适当的地方 as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to the following:

1. Durable Medical 设备 (DME) which (a) can withstand use (i.e., 通常可以租用), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, 家用透析设备, hospital beds and mattresses, 铁肺, orthopedic frames and traction devices, 氧气帐篷, 病人电梯, 呼吸机, 喷雾器, 助行器和轮椅.
.

讨论

第三条.A.(6)(d) of the 雇主 Benefit Plan provides benefits for medical equipment when determined to be medically necessary by a physician. Medical equipment is defined in Q&A 81-38 as equipment and supplies suitable for home use and customarily used to service a medical purpose.

The Trustees have previously addressed the question of coverage for a lift for wheelchair-bound beneficiaries in RODs 81-131, 88-261, and 98-049 (copies enclosed). The opinion of the Trustees in those cases was that a wheelchair lift is not appropriate for use in the home and is not primarily and customarily used to serve a medical purpose. 就像前面提到的罗德一样, the lift in this case would be used for transportation purposes outside the home and would not be used to serve a medical purpose. Therefore, the lift is not a covered benefit under 第三条.A.(6)(d) of the 雇主 Benefit Plan.

受托人的意见

根据第三条.A(6)(d) of the 雇主 Benefit Plan, Respondent is not required to provide benefits for Complainant’s spouse’s power lift.