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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: 88-321 - 1990年10月12日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas K. Saggau,
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 health benefits coverage for the purchase of a wig under the terms of the 雇主 Benefit Plan.
背景事实
雇员的女儿患有拔毛癖, a medical condition that has resulted in a complete loss of all her scalp hair. The 雇主 has refused to provide benefits for the purchase of a wig.
争端
Is the 雇主 required to provide benefits for the purchase of the 员工’s daughter’s wig?
双方立场
Position of the 原告: The 员工 asks whether the 雇主 is required to pay for the 员工’s daughter’s wig prescribed by her physician as a total scalp hair prosthesis that would enable her to engage in activities outside the home.
Position of the 被申请人: The 雇主 is not required to provide benefits for the 员工’s daughter’s wig because a wig is not listed among the covered prosthetic devices under 第三条. A. (7) (a) of the 雇主 Benefit Plan and because benefits are not provided for personal comfort items not necessary to the treatment of an illness or injury. The 雇主 states that its position is further supported by a previous decision of the Trustees in ROD 88-154.
相关的规定
The Introduction to 第三条 of the 雇主 Benefit Plan states in pertinent part:
第三条-福利
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定….
第三条. A. 《皇冠搏彩中心网站》(7)(a)的相关部分规定:
(7) 其他好处
(a) 矫形和假体设备
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
包括以下类型的设备:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
These include artificial eyes, noses, hands (or hooks), feet, arm, legs and ostomy bags and supplies.
2. 乳房切除后假体.
3. 腿部，手臂，背部和颈部支架.
4. 桁架
5. Stump stockings and harnesses when these devices are essential for the effective use of an artificial limb. An examination and recommendations by an orthopedic physician is required.
…
6. Surgical stockings (up to two pairs per prescription with no refills) when prescribed by a physician for surgical or medical conditions. The Plan will not pay Beneficiaries for support hose, garter belts, etc.
7. Orthopedic shoes when specifically prescribed by a physician or licensed podiatrist for a Beneficiary according to orthopedist specifications, 包括矫形鞋
附在支架上，必须修改以适应支架. 库存矫形鞋不提供福利.
8. Orthopedic corrections added to ordinary shoes by a physician or licensed podiatrist. 福利只提供对鞋的矫正.
第三条. A. (11)(a) 9. 和27. 的“雇主福利计划”声明:
(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:
…
9. 个人服务，如理发服务, 客人餐和床, telephone or rental of radio or television and personal comfort items not necessary to the treatment of an illness or injury.
…
27. Any types of services, supplies or treatments not specifically provided by the Plan.
讨论
The Introduction to 第三条 of the 雇主 Benefit Plan states that covered services shall be limited to those services that are reasonable and necessary for the diagnosis or treatment of an illness or injury and that are given at the appropriate level of care, 或计划另有规定. 第三条. A. (7) (a) of the Plan provides health benefits coverage for orthopedic and prosthetic devices prescribed by a physician when medically necessary. 第三条. A. (11)(a) 9. of the Plan states that benefits are not provided for personal services and personal comfort items not necessary to the treatment of an illness or injury. 此外，第三条. A. (11)(a) 27. 声明不为任何类型的服务提供福利, 本计划未特别规定的供应品或治疗.
In this case, the 员工’s daughter experienced hair loss as a result of a medical condition. The 雇主 has refused to provide benefits for the purchase of a wig prescribed by the 员工’s daughter’s physician as a total scalp prosthesis. The 员工’s daughter’s wig serves as a replacement for the hair she has lost because of her condition. However, a wig is not one of the prosthetic devices listed under 第三条. A. (7) (a)可为其提供利益的计划. 在ROD 88-154(附在这里的副本)中，受托人决定
that benefits are not provided for wigs necessary because of hair loss caused by disease or chemotherapy treatment as such wigs are considered cosmetic or personal comfort items not necessary to the treatment of an illness or injury. Because benefits are not specifically provided by the plan for the purchase of wigs and because a wig is a cosmetic item not necessary to the treatment of the 员工’s daughter’s condition, the 雇主 is not required to provide benefits for the purchase of the 员工’s daughter’s wig.
受托人的意见
The 雇主 is not required to provide benefits for the purchase of the 员工’s daughter’s wig.