______________________________________________________________________________

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: 84-129——1986年2月24日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长，受托人. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for eyeglasses under the terms 雇主福利计划的成员.

背景事实

The 员工 had surgery on his right eye for cataract removal and intraocular lens (IOL) implant. Three months later, similar surgery was performed on his left eye. 每次手术后, the attending ophthalmologist prescribed a new eyeglass lens for the affected eye in order to restore visual acuity to the same level of acuity (20/20, 与校正, in each eye) the 员工 had prior to surgery. The eyeglasses the 员工 wore before his cataract surgery did not provide the additional correction needed as a result of the loss of acuity caused by the surgery. 除了, they did not have the ultraviolet absorbing lenses which are needed to protect the eyes following cataract surgery.

问题或争议

Is the 雇主 responsible for paying benefits for the eyeglasses the 员工 received following cataract surgery and IOL implants?

各方立场

Position of the 员工: The 雇主 is responsible for payment of the benefits for the eyeglasses the 员工 required to correct his vision following cataract surgery and IOL implants.

Position of the 雇主: The 雇主 is not responsible for payment of benefits for both eyeglasses and IOL implants because the IOL implants by themselves are corrective lenses, and payment for them satisfies the 雇主’s responsibility for the provision of benefits for eyeglasses or lenses required because of a surgically caused refractive error. In this case, the eyeglasses could only be covered under the vision care program. 然而, the 雇主 paid benefits for eyeglasses under the vision care program less than two years before the beneficiary received the eyeglasses following the cataract surgery and IOL implants, so that vision care benefits were not payable under the frequency limits of the vision care program.

相关的规定

第三条. 一个节. (11) (a) 22. 的“雇主福利计划”规定:

(11)一般除外条款

(a) 除了 to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

22. 眼镜或镜片, except when medically required because of surgically caused refractive errors or as otherwise provided in section A(9).

讨论

根据第3条. A (11) (A)条. 雇主福利计划的成员, benefits are provided for eyeglasses or lenses when medically required because of a surgically caused refractive error. Cataract surgery causes a refractive error because it involves removal of the lens. The marked decrease in visual acuity associated with removal of the natural lens requires the use of a prosthetic lens or a combination of prosthetic lenses to restore vision. The types of prosthetic lenses which are available include IOLs, contact lenses, and eyeglass lenses.

In this case, the 员工 wore eyeglasses for myopia before surgery. 手术后, 因此, with IOL implants–the 员工 had hyperopia and astigmatism in one eye and myopia and astigmatism in the other eye. The degree of refractive error which existed after the surgery was markedly different from the degree of refractive error which existed prior to the surgery, and new eyeglasses were needed in conjunction with the IOLs for the 员工 to have normal visual acuity. Correction of the refractive error caused by the surgical removal of the 员工’s natural lenses required both IOLs and prosthetic-lens eyeglasses. 除了, ultraviolet absorbing lenses were prescribed for the eyeglasses to protect the 员工’s eyes from potentially harmful rays from the sun.

Because a combination of IOLs and eyeglasses is medically required to correct the Complainant’s surgically caused refractive error, both types of lenses are covered under 第三条 A (11) (a) 22.

受托人的意见

The 雇主 is responsible for payment of the charges for the combination of lenses, 这是, 眼内植入物和眼镜, which the 员工 required as the result of surgically caused refractive error.