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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: 88-250 - 1990年8月22日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 motorized chair under the terms of the 雇主 Benefit Plan.
背景事实
The Pensioner’s sixteen-year-old daughter has hypohidrotic ectodermal dysplasia (HED), a congenital abnormality in the development of her sweat glands that prevents her from adequately controlling her body temperature. 结果，她患上了手部和脚部的慢性皮炎. She was seen by a dermatologist who prescribed treatment consisting of tar emulsion soaks and the application of ointment to the affected areas.
在10月28日的信中, 1988, the Pensioner’s daughter’s physician stated that her condition prevents her from wearing shoes and going to school. He prescribed a motorized three-wheeled chair for her use so that she could go to school without shoes. 这位养老金领取者于1989年2月17日购买了这把电动椅子.
The physician subsequently prescribed special cooling shoes for the Pensioner’s daughter that are part of a thermal control system. The system was purchased with contributions made to the HED Foundation on behalf of the Pensioner’s daughter. 根据养老金领取者的配偶, the cooling shoes are like a booty that can be worn inside her daughter’s regular shoes. Cooling is provided by a temperature-controlled liquid flowing through the shoes which are connected to a portable cooling unit. The Pensioner’s spouse states that her daughter continues to use the motorized chair because she cannot carry all the supplies -power unit, 冷却液, 等.)需要在离家时长时间使用冷却鞋. 养老金领取者的配偶声称她的女儿在学校使用椅子, 购物, 以及娱乐活动.
The 雇主 has denied coverage for the purchase of the motorized chair on the grounds that such equipment is not medically necessary and is not intended for home use. 最初, the 雇主 also denied coverage for the use of the special cooling shoes and attendant 冷却液s and supplies, 但在进一步审查之后, 雇主决定为这些设备提供保险. 因此, the charges pertaining to the cooling shoes and supplies related to their use are no longer in dispute.
争端
Is the 雇主 required to provide benefits for the Pensioner’s daughter’s motorized chair?
双方立场
Position of the Pensioner: The 雇主 is required to provide benefits for the Pensioner’s daughter’s motorized chair because it has been determined by her physician that this equipment is medically necessary.
Position of the 雇主: The 雇主 is not required to provide benefits for the motorized chair because it is not intended for home use and it is not medically necessary for the treatment of her illness.
相关的规定
第三条. A. 雇主福利计划第(6)(d)条规定:
(6) 家庭保健服务和设备
(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州在相关部分:
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) generally is not useful to a person in the absence of an illness or injury, (d)适合在家中使用. 包括DME项目的例子是手杖, 洁具, 以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
根据第三条. A. (6) (d)雇主福利计划, benefits are provided for medical equipment suitable for home use when determined to be medically necessary by a physician. 所涵盖的医疗设备类型由Q进一步界定&A 81-38, which states that covered medical equipment is that which (a) can withstand use; (b) is primarily and customarily used to serve a medical purpose; (c) generally is not useful to a person in the absence of an illness or injury; (d)适合在家中使用. 因此,问&A 81-38 clearly applies only to medical equipment that is medically necessary for home use.
The Trustees have previously addressed the issue of coverage for specialized types of wheelchairs such as electric wheelchairs and motorized three-wheeled chairs in RODs 84-232, 84-270及84-340(随函附上副本). 在每个决定中, the Trustees concluded that the specialized wheelchair was not covered because it had not been established that it was medically necessary for the patient’s home use. A wheelchair is considered medically necessary if the patient’s medical condition is such that, 不使用轮椅, 病人将被限制在床上或椅子上. Specialized types of wheelchairs may be appropriate and medically necessary if a beneficiary meets the coverage requirements for a wheelchair, 但无法手动操作.
在这种情况下, the Pensioner’s daughter’s physician recommended that she obtain a motorized three-wheeled chair to allow her to go to school without shoes. 所提供的文档并没有表明这一点, 没有电动三轮轮椅, the Pensioner’s daughter would be confined to a bed or chair or that she is unable to ambulate independently. 因此, the Pensioner’s daughter does not meet the coverage requirements for a wheelchair. Because the motorized three-wheeled chair prescribed in this case is not medically necessary for the Pensioner’s daughter’s home use, 它不属于本计划的承保范围.
受托人的意见
The 雇主 is not required to provide benefits for the Pensioner’s daughter’s three-wheeled motorized chair.