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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 88-516 – 一九九二年四月十四日

Board of Trustees: 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 for durable medical equipment under the terms of the 雇主 Benefit Plan.

背景事实

The spouse of a 养老金领取者 fell in her home on September 6, 1990, 背部受伤, 下腰椎, pelvis and bruising her buttocks. Her 医生tor prescribed the use of a donut ring to ease the discomfort associated with sitting. The 雇主 denied the $8.30 charge as a non-covered expense, because the ring was a personal comfort item, and not for the treatment or diagnosis of an injury or illness.

争端

Is the 雇主 required to pay for the donut ring prescribed by the 养老金领取者’s spouse’s physician in relation to injuries she sustained on September 6, 1990?

Positions of the Parties

Position of the 养老金领取者: The 雇主 is required to pay for the donut ring, as it was medically necessary and prescribed by the 医生tor, in accordance with 第三条. A. (6)(d).

Position of the 雇主: The 雇主 is not required to pay for the donut ring, as it is a convenience item designed for comfort, and is not medically necessary.

Pertinent Provisions

第三条. A. (6)(d) of the Group Plan states in part:

(d) 医疗设备

Benefits are provided for rental or, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.

讨论

第三条. A. (6)(d) allows for the purchase of medical equipment deemed to be medically necessary by a physician. A Fund’s medical consultant has reviewed this file. He notes that the donut ring is useful for removing pressure from a sore point and distributing it to the surrounding area; it is also used in the treatment of fractured or bruised coccyx bones as well as for treatment of abscesses or sores in the perianal region. The consultant is of the opinion that the donut ring was properly prescribed and a medically justified medical equipment item. Therefore, the Trustees find that the 雇主 is responsible for the payment of the donut ring.

Opinion of the Trustees

The 雇主 is responsible for the payment of the medical equipment pursuant to 第三条. A. (6)(d) of the Group Plan.