_____________________________________________________________________________
受托人的意见
_____________________________________________________________________________
在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-455 - 1991年10月29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 an insulin injection device under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s 19-year-old son has juvenile onset diabetes mellitus, a chronic form of diabetes involving insulin deficiency, and he receives insulin injections twice daily. His physician has stated that he has good diabetic control, but he frequently has a small amount of bleeding at the injection site and has numerous bruises. The physician has prescribed a Medi-Jector needle-free insulin injection device, stating that he thinks its use will decrease the 员工’s son’s hemorrhagic response to insulin Injections and will relieve a disturbing side effect from injections with a needle. The 雇主 has denied benefits for the purchase of -the insulin Injection device.
争端
Is the 雇主 required to provide benefits for the insulin injection device?
双方立场
Position of the 员工: The 雇主 is required to provide benefits for the needle-free insulin injection device because injections with a needle have resulted in bleeding and other problems.
Position of the 雇主: The 雇主 is not required to provide benefits for the insulin injection device because it is an item of convenience and is not medically necessary for the treatment of the 员工’s son’s diabetes; regular insulin syringes would serve the same purpose at a more reasonable cost.
相关的规定
第三条. A. (6)(d) of the 雇主 Benefit Plan provides:
(6) 家庭健康服务 & 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,
第三条. 部分一个. (6)(d)和(e). (7) (a)及(d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
A. Under the 家庭健康服务 and 设备 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:
…
2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue pads”), supplies for home management of open or draining wounds, heating pads (for therapeutic use only] and insulin needles and syringes.
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, 州, under the 家庭健康服务 and 设备 provision, benefits are provided for certain types of medical equipment and supplies, including insulin needles and syringes.
A Funds’ medical consultant has reviewed this file, including a letter from the 员工’s son’s physician. He notes that the prescribed Medi-Jector is an alternative means of delivering the patient’s insulin by using a jet of air instead of a needle. The consultant finds no medical documentation to indicate that the patient’s bleeding cannot be controlled by better technique using traditional means of insulin injection. The consultant further 州 there is no medical evidence that the patient has a bleeding disorder and no medical evidence that the Medi-Jector produces less bleeding or a smaller contusion. The consultant is of the opinion that the use of a Medi-Jector in this case would not provide any medical advantages over a conventional hypodermic insulin syringe and is not medically necessary.
Since the insulin injection device prescribed in this case is not medically necessary, the 雇主 is not required to provide benefits for it under the terms of the 雇主 Benefit Plan.
受托人的意见
The 雇主 is not required to provide benefits for the insulin injection device.