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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: 88-039 - 1989年2月14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 health benefits coverage for home health aide services under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse has advanced multiple sclerosis and is confined to a wheelchair. The muscular weakness associated with the disease causes her to have minimal arm movement, 视力问题, 小便失禁和吞咽困难, 因此需要完全的行动辅助, 个人护理及喂养. The 员工’s spouse’s physician has noted on several occasions that, 而不需要熟练的护理, the 员工’s spouse requires the assistance of nurses’ aides twenty-four hours a day.

The 雇主 provided benefits for home care services for the 员工’s spouse from September 24, 1987年至3月14日, 1988. The 雇主 provided such benefits under its case management program in order to avoid hospitalization expenses. The 雇主 did not make a determination that the services were covered under 第三条. A. (6)雇主福利计划. 雇主于3月9日通知了雇员, 1988 that benefits for the home care services would be terminated on March 14, 1988.

3月14日起, 1988年至5月16日, 1988, the 员工’s spouse received home health aide services twenty-four hours a day, 一周七天. 助手们帮助洗澡, 沙拉酱, 定位, 烹饪, 喂养, 按摩, 肠道和膀胱管理, 皮肤护理, oral medication administration and routine range of motion exercises. Licensed nurses performed periodic, unbilled visits to supervise the care furnished by the aides. Documentation of the visits by licensed personnel was not provided, and agency representatives were not able to specify the frequency of such visits. The 雇主 denied benefits for the services rendered by the home health aides from March 14, 1988年至5月16日, 1988.

争端

Is the 雇主 required to provide benefits for home health aide services rendered to the 员工’s spouse from March 14, 1988年至5月16日, 1988?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the home health aide services rendered to the 员工’s spouse from March 14, 1988年至5月16日, 1988, 因为这在医学上是必要的.

Position of the 雇主: The 雇主 is not required to provide benefits for the 员工’s spouse’s home health aide services from March 14, 1988年至5月16日, 1988, 因为这种照顾本质上是监护.

相关的规定

第三条. A. (6)雇主福利计划的相关部分规定:

(6) 家庭健康服务 & 设备

(a) 一般规定

为家庭保健服务提供福利, including nursing visits by registered nurses and home health aides, 以及各种康复疗法, subject to the following conditions and approval of the Plan Administrator.

1. 受益人必须接受医生的治疗.

2. The Beneficiary’s medical condition must require skilled nursing care, 物理治疗, 或者每60天至少进行一次语言治疗.

3. The physician must initiate a treatment plan and specify a diagnosis, the Beneficiary’s functional limitations and the type and frequency of skilled services to be rendered.

4. 受益人必须待在家中. The services must be provided by a certified home health agency.

(c) 专业护理

Benefits are provided for skilled nursing care rendered by a registered nurse as a home health service when a Beneficiary’s condition has not stabilized and a physician concludes that the Beneficiary must be carefully evaluated and observed by a registered nurse. The Plan Administrator may request an evaluation visit to the Beneficiary’s home.
第三条. A. (11)(a) 8. 的“雇主福利计划”规定:

(11) 一般的除外

(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:

8. 监护、康复或休养治疗.

讨论

第三条. A. (6)雇主福利计划 provides that benefits for home health services, 包括由注册护士和家庭健康助理进行探访, 是在某些情况下提供的. 不提供福利, 例如, unless the Beneficiary’s medical condition requires skilled nursing care, 物理治疗 或者每60天至少进行一次语言治疗. 此外，第三条. A. (11) (a) 8. of the Plan provides that benefits are excluded for custodial care.

Skilled nursing care is generally considered to encompass those services that are reasonable and necessary for the treatment of an illness or injury and which must be performed by or under the direct supervision of a licensed nurse if the safety of the patient is to be assured and the medically desired result is to be achieved. Custodial care is a lower level of care and constitutes services that assist an individual to meet the activities of daily living (i.e.、个人护理、喂食、如厕等.).

The 员工’s spouse suffers from advanced multiple sclerosis. 她被限制在轮椅上，手臂活动很少, 视力问题, 尿失禁, 还有吞咽困难. 然而, there is no evidence that her medical condition requires skilled nursing care as opposed to custodial care.

The care received by the 员工’s spouse was provided by unlicensed nurses’ aides. The tasks performed by the nurses’ aides could have been performed by the average lay person with a reasonable amount of instruction and did not require the skills of licensed personnel. The care provided the 员工’s spouse was clearly custodial in nature; she did not receive or require skilled nursing care during the period in question. Consequently, the home health aide care is not a covered benefit under the Plan.

受托人的意见

The 雇主 is not required to provide benefits for the home health aide services rendered to the 员工’s spouse from March 14, 1988年至5月16日, 1988.