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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 84-270——1987年4月28日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
威廉·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 health benefits coverage for a motorized chair under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse is being treated for chronic rheumatoid arthritis. Her condition has deteriorated to the point that her range of independent ambulation is very limited. The effects of the condition include weakening of her wrists and hands, so that she cannot use a manual wheelchair. Her physician prescribed a motorized three-wheel chair (sometimes referred to as a “scooter chair”) for her use. According to her physician and to a consultant rheumatology specialist engaged by the 雇主 to examine the 员工’s spouse, she would essentially be housebound without the motorized chair. The 雇主 has denied coverage for the motorized chair on the grounds that it is not medically necessary.
争端
Is the 雇主 responsible for providing benefits for the motorized chair?
各方立场
Position of the 员工: The 雇主 is responsible for paying benefits for the motorized chair because it is medically necessary for the 员工’s spouse’s crippling arthritic condition, and it would improve her psychological condition.
Position of the 被申请人: The 雇主 is not responsible for paying benefits for the motorized chair because it would only be used outside the home (e.g., to go shopping and for family outings) and would therefore be considered a convenience item rather than a piece of medically necessary equipment which could be covered under Plan provisions.
相关的规定
第三条. A. (6) (d)雇主福利计划 states:
(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.
Q&81-38州:
主题: 医疗设备和用品
参考资料:1950年修订 & 1974年福利计划 & 信托皇冠搏彩中心网站,
第三条, Section A (6) (d) and (e), and A (7) (a) and (d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
A. Under the Home Health Services and Equipment provision, 提供租金和福利, 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 医疗设备 (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. 包括DME项目的例子是手杖, commodes and other safety bathroom equipment, 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. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue Pads”), supplies for home management of open or draining wounds, heating pads (for therapeutic use only) and insulin needles and syringes.
3. Oxygen, as specified in Article Ill, Section A (6) (e).
讨论
根据第三条. A. (6) (d)雇主福利计划, benefits are provided for the purchase of medical equipment suitable for home use when determined by a physician to be medically necessary. Q&A 81-38 states that covered durable medical equipment is equipment that a) can withstand use, 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. 因此,问&A 81-38 clearly applies only to equipment that is medically necessary for home use.
A consulting physician’s report indicates that during examination the 员工’s spouse was able to ambulate a distance of 20 feet without assistance. A three wheel motorized chair, therefore, is not medically necessary for her use. The purpose for the device would be to enable the 员工’s spouse to leave the household for nonessential activities. Therefore the three wheel motorized chair in this case would serve as a convenience item and would not be medically necessary. As such it is not a covered benefit under the 雇主 Benefit Plan.
受托人的意见
The 雇主 is not responsible for providing benefits for the motorized chair to be used by the 员工’s spouse.