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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: 84-288——1987年5月27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 benefits for out-of-area transportation, 运动器材, and an electronic air cleaner under the terms of the 雇主 Benefit Plan.

背景事实

该员工被转到罗切斯特的梅奥诊所, 明尼苏达州 for an evaluation of chronic pain associated with tension vascular headaches and of related chemical dependency which had been unsuccessfully treated locally. Once he was found to be a suitable candidate for treatment at the Mayo Clinic, he returned for a month’s admission in the 诊所’s chemical dependency program. 随后, the 员工 returned to Rochester to participate in Mayo Clinic’s pain management program at St. 玛丽医院. The chemical dependency and pain management programs both involved family counseling, so the 员工’s spouse made two trips from the family residence in Utica, 从肯塔基到罗切斯特, 明尼苏达和后面. 除了交通费, 雇员及其配偶的食宿费用自理. 完成疼痛管理项目后, an exercise bike and two sets of sand bag weights were prescribed for the 员工’s home use in maintaining his pain management regimen.

在一个不相关的处理中, the 员工’s daughter was seen by the family 医生tor for allergy problems, 医生给她开了一个电子空气净化器.

付款 of benefits for all of the incurred expenses described above has been denied by the 雇主.

争端

Is the 雇主 responsible for the provision of benefits for transportation and lodging for the 员工 and his spouse, 供雇员使用的健身单车及沙袋砝码, 以及为雇员的女儿购买电子空气净化器?

双方立场

Position of the 员工: The 雇主 is responsible for provision of benefit for the transportation and lodging and the items of equipment, 因为这些都是本计划所涵盖的服务.

Position of the 雇主: The 雇主 is not responsible for the provision of benefits for lodging and transportation as the medical care could have been received closer to the beneficiary’s home and prior approval was not requested. 除了, the 雇主 is not responsible for providing benefits 对于运动器材 for the 员工 or for the electronic air cleaner for the 员工’s daughter because those items of equipment are not covered under the Plan.

相关的规定

第三条. A. 雇主福利计划第(7)(e)条规定:

(e) 救护车及其他交通工具

为往返医院的救护车运输提供补助, 诊所, 医疗中心, 医生的办公室, 或者是专业的护理机构, 当医生认为医学上有必要时.

With prior approval from the Plan Administrator benefits will be also be provided for other transportation subject to the following conditions:

1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out-of-area 医疗中心.

2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or 诊所 for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.

3. 如果受益人在运输过程中需要护送, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.

第三条. A. 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.
条病. A. (11) (a) 23. 的“雇主福利计划”部分述明:

(11) 一般的除外

(a) 除本计划中另有规定的特定除外事项外, 以下情况也不提供福利:

23. 运动器材

27. Any types of services, supplies or treatments not specifically provided by the Plan.

讨论

Benefits for transportation expenses to an out-of-area 医疗中心 are provided for the beneficiary if the needed medical care is not available near the beneficiary’s home. Benefits are also provided for travel expenses for an escort if the beneficiary requires one during transportation. These benefits are provided when prior approval has been obtained from the Plan Administrator. 在目前的情况下, benefits were provided for the care received and for the initial travel to obtain the evaluation. The Plan Administrator has denied subsequent coverage for travel and lodging costs for the 员工 and his wife based on the position that similar care could have been obtained at a closer facility and that prior approval for the trips to Rochester, 明尼苏达州既不寻求也不授予. 在尤蒂卡附近有几个药物依赖治疗项目, 肯塔基而不是梅奥诊所, 有两个疼痛管理项目, 在印第安纳波利斯, 印第安纳和纳什维尔, 田纳西州, 比罗切斯特更近, 明尼苏达州.

The Complainant has asked how he would know which facilities are covered and which are not. The requirements to obtain prior approval have been established to address such an issue. The only provision for accompanied travel in the Plan is for an escort when the physician submits a satisfactory justification for the need. 在这种情况下, the participation of the spouse in the therapy process is not a specifically stated benefit under the Plan and therefore is not covered.

运动器材已由受托人在Q中处理&A 81-38 (copy enclosed herein); items such as the bicycle and the sand bags are convenience items. 虽然与申诉人的待遇无关, 他的家属的电子空气过滤器也是如此. 在ROD 178(副本随函附上), 受托人认为该项目具有方便的性质.

受托人的意见

The 雇主 is not responsible for the provision of benefits coverage for the travel and lodging expenses incurred by the 员工 and his wife, 对于运动器材, 或用于雇员家属的电子空气过滤器.