______________________________________________________________________________
受托人的意见
______________________________________________________________________________
在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 84-261——1987年9月18日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. 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 benefits for a seat lift chair under the terms of the 雇主 Benefit Plan.
背景事实
The 养老金领取者 is being treated for severe rheumatoid arthritis of the hips, knees, and ankles. 关节炎导致了这位老人髋部和右脚踝关节的融合. 作为治疗计划的一部分, the physician prescribed a seat lift chair (more commonly referred to as “seat lift”) to prevent bed or chair confinement, 防止患者关节进一步融合，方便其活动.
座位升降是在5月29日规定的, 1985 on a rental basis with prospective purchase if the seat lift proved to be beneficial. The 雇主 refused to pay any benefits for it on the grounds that seat lift chairs are not covered under the Plan because they are not primarily and customarily used to serve a medical purpose and they would be useful in the absence of an illness or injury. The medical equipment company removed the seat lift from the 养老金领取者’s home in July 1986 due to lack of payment by the 雇主’s insurance carrier.
争端
雇主是否负责支付座位升降机的福利?
各方立场
Position of the Employee: The Employee contends that since his arthritis prevents him from lifting himself out of a chair, the seat lift is medically necessary and therefore is covered under the 雇主 Benefit Plan.
Position of the 雇主: The 雇主 contends that the seat lift chair is not covered under the Plan because the chair is not primarily and customarily used to serve a medical purpose and would be useful in the absence of an illness or injury.
相关的规定
第三条A. 1984年雇主福利计划第(6)(d)条规定:
(d) 医疗设备
提供租金或租金福利, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
问和答81-38:
主题: 医疗设备和用品
引用: 修改1950 & 1974年福利计划 & 信托，第III条，第A (6) (d)和(e)条以及第A (7) (A)和(d)条
问题:
本计划涵盖哪些医疗设备和用品?
答:
A. 根据家庭保健服务和设备条款, 提供租金和福利, 在计划管理人决定的适当情况下, 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. 这些物资和设备包括但不限于以下内容:
1. (a)能够承受(i)使用的耐用医疗设备(DME).e., 通常可以租用), (b)主要并通常用于服务医疗目的, (c)在没有患病或受伤的情况下，一般来说对人是无用的, (d)适合在家中使用. 包括DME项目的例子是手杖, 盥洗用具及其他安全卫浴设备, 家用透析设备, 医院的病床和床垫, 铁肺, 骨科框架和牵引装置, 氧气帐篷, 病人电梯, 呼吸机, 喷雾器, 助行器和轮椅.
2. 维持居家或卧床的受益人生活所需的医疗用品. 有盖补给的例子是灌肠补给, 一次性床单和卫生巾(也称为“Chux”或“蓝色卫生巾”), 家庭管理开放性或渗水伤口的用品, 加热垫(仅用于治疗)和胰岛素针和注射器.
3. 第III条第A (6) (e)节规定的氧气.
讨论
第三条A. (6)(d) of the 雇主 Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&81-38州涵盖的设备包括, " (a)能够承受(i)使用的耐用医疗设备(DME).e., 通常可以租用), (b)主要并通常用于服务医疗目的, (c)在没有患病或受伤的情况下，一般来说对人是无用的, (d)适合在家中使用.“为雇员配偶租用的升降椅符合所有四项标准. 首先，它可以承受重复使用. 第二，座椅升降主要并且通常用于医疗目的.e.，协助行动不便人士坐立. 第三, the lift function of the chair would not be useful for persons who do not have an illness or injury that causes impairment of mobility. 第四, the seat lift can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
虽然一种二甲醚可能符合Q&A 81-38，这是第三条规定的. A. (6)(d) of the 雇主 Benefit Plan only if it is medically necessary for the treatment of an illness or injury. ROD 84-135(附件副本), the Trustees concluded that the prescribed seat lift was covered under the Plan because its medical necessity in that particular case had been established. 相反, ROD 84-219(附件副本), the Trustees concluded that the prescribed seat lift was not covered under the Plan because its medical necessity in that case had not been established. The 医疗保险 program has established five criteria that provide a useful framework for determining the medical necessity of a seat lift in a specific case. Those criteria are: 1) the patient is diagnosed as having severe arthritis of the hip or knee or a neuromuscular disease; 2) the patient can benefit therapeutically from use of the device; 3) the seat lift is included in the physician’s course of treatment; 4) the seat lift is likely to effect improvement, or arrest or retard deterioration in the patient’s condition; and 5) the severity of the condition is such that the alternative would be chair or bed confinement.
在这种情况下，所有五项医疗保险标准都已满足. 第一个, the 养老金领取者 has been diagnosed as having rheumatoid arthritis of such severity that it has caused fusion of the hips and right ankle. 第二，开处方的医生已经声明养老金领取者在治疗上受益
从座位提升椅子，增加流动性和帮助循环. He stated that the 养老金领取者 developed a decubitus ulcer (pressure sore) on his right hip after the seat lift was removed from
家. 第三，座椅提升是由治疗养老金领取者关节炎的医生开的处方. 第四, the physician has stated that the seat lift aids in retarding deterioration of the 养老金领取者’s condition by preventing further fusion of the joints. 第五, the physician has stated that the seat lift prevents bed or chair confinement because the 养老金领取者 is not able to get out of a chair independently. 在回顾上述资料及其他临床资料后, a Funds’ medical consultant concurred with the prescribing physician’s finding that in this case the seat lift is medically necessary for the treatment of the 养老金领取者’s arthritis.
The seat lift that was prescribed for the 养老金领取者 is an item of durable medical equipment which may be covered under the Plan, 和养老金领取者,医生已经确定这是医学上必需的. 因此，座椅升降椅是雇主福利计划所涵盖的福利.
受托人的意见
符合雇主福利计划的条款, the 雇主 is responsible for providing benefits for the rental of the seat lift chair for the period of time (May 1985 through July 1986) the seat lift was in the 养老金领取者’s home and is also responsible for providing benefits for the continued use of a seat lift chair by the 养老金领取者 pursuant to Plan provisions.