_____________________________________________________________________________
受托人的意见
_____________________________________________________________________________
在再保险
原告: 未亡配偶
被申请人: 雇主
ROD案例编号: 88-430——1991年12月16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 seat lift under the terms of the 雇主 Benefit Plan.
背景事实
The Complainant is being treated for severe osteoarthritis of both hips. She is an insulin-dependent diabetic and her vision is impaired as a result of diabetic retinopathy. She previously underwent bladder surgery, has been evaluated for a ruptured disc, and has a history of cancer of the uterus. 作为她治疗计划的一部分, her physician has prescribed a seat lift chair (more commonly referred to as a “seat lift”). Two additional physicians have stated that the seat lift is necessary to facilitate her mobility. One of the physicians states that improved mobility would in turn help her diabetic status. The 雇主 has denied benefits for the seat lift.
争端
Is the 雇主 required to provide benefits for the seat lift prescribed for the Complainant?
双方立场
Position of the 原告: The 雇主 is required to provide benefits for the seat lift because it is medically necessary.
Position of the 被申请人: The 雇主 is not required to provide benefits for the seat lift because the medical information does not document that a seat lift is medically necessary in this case.
相关的规定
第三条A. (6)(d) of the 雇主 Benefit Plan states:
(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&第81-38号决议在相关部分指出:
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,
Article III, Sections A (6) (d) and (e), and (7) (a) and (d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, 在适当的地方 as determined by the Plan Administrator, 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. These supplies and equipment include, but are not limited to the following:
1. Durable 医疗设备 (DME) which (a) can withstand use (l.e., 通常可以租用), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, 家用透析设备, 医院的病床和床垫, 铁肺, 矫形框架和
traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
讨论
第三条A. (6)(d) of the 雇主 Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states that covered equipment includes, “Durable 医疗设备 (DME) which (a) can withstand use (i.e., 通常可以租用), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home.在第84-135章, 84-219 and 84-261 (copies enclosed herein) the Trustees have determined that a seat lift meets the criteria for durable medical equipment for which benefits may be provided under 第三条A. (6)(d).
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6)(d) of the 雇主 Benefit Plan only if it is medically necessary for the treatment of an illness or injury. A Funds’ medical consultant has reviewed this case, including letters from the Complainant’s physicians. The consultant has stated that these letters document the patient’s severe osteoarthritis of the hips and her difficulty in getting out of a chair to ambulate because of this condition. The consultant has advised that a seat lift is medically necessary for the treatment of the patient’s arthritis of both hips to prevent chair confinement and to retard deterioration of her condition, which would occur if she was unable to get out of her chair for frequent ambulation.
Inasmuch as the seat lift prescribed for the Complainant is a medically necessary item of durable medical equipment, it is a covered benefit under the 雇主 Benefit Plan.
受托人的意见
The 雇主 is required to provide benefits for a seat lift, as was prescribed for the Complainant.