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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: 84-504 – 1988年1月19日
Board of Trustees: 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 prescription drugs under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse has hypoglycemia (low blood sugar) and weighs 89 1/2 pounds. Because she cannot tolerate high protein-low carbohydrate, 笨重的食物, her physician has prescribed a nutritional formula, 确保+, to be taken between meals three times a day as a diet supplement. 确保+ is sold over the counter and does not 需要处方.
The 雇主 has denied coverage for the nutritional supplement because a prescription is not required in order to purchase the diet supplement.
争端
Is the 雇主 responsible for the provision of prescription drug benefits for the 员工’s spouse’s diet supplement?
Positions of the Parties
Position of the 员工: The 雇主 is responsible for the provision of prescription drug benefits for the 员工’s spouse’s diet supplement because it is medically necessary for the treatment of her hypoglycemia.
Position of the 雇主: The 雇主 is not responsible for providing prescription drug benefits for the 员工’s spouse’s diet supplement because a prescription is not required in order to purchase the diet supplement.
相关的规定
第三条. A. (4)(a) and (b) of the 雇主 Benefit Plan state in part:
(4) 处方药
(a) 提供的福利
Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law 需要处方) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or a nonoccupational accident…
(b) 利益排除在外
Benefits shall not be provided under paragraph (4)(a) for the following:
4. Any medication not specifically provided for in (a) above.
讨论
根据第三条. A. (4) of the 雇主 Benefit Plan, benefits are provided only for those drugs which, by Federal or State law, 需要处方. Medication that can be obtained over the counter without a prescription is excluded from coverage. The Trustees have previously concluded in Resolutions of 争端 81-561, 84-098 and 84-502 (copies enclosed herein) that benefits are not provided under the 雇主 Benefit Plan for nutritional supplements which do not 需要处方. 在这种情况下, although the 确保+ needed by the 员工’s spouse was prescribed by a physician, no prescription is required for purchase. Therefore, benefits are not provided for this supplement under the 雇主 Benefit Plan.
Opinion of the Trustees
The 雇主 is not responsible for the provision of benefits for the diet supplement 确保+.