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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:88-691 - 1993年7月8日

董事会:Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for an electric breast pump under the terms of the Employer Benefit Plan.

背景事实

On November 3, 1992 the Employee’s spouse purchased an electric breast pump for $595.00 to assist her in the expression of breast milk. 在购买前的讨论中, the Employer stated it considered the breast pump a convenience item and not eligible for benefits under the Employer Benefit Plan, 引用ROD 84-537.

The Employer’s claims administrator denied payment for the pump, 声明, “durable medical equipment supplied for aesthetic or convenience reasons is not covered.” The Employer further stated that the attending physician advised that the patient had requested the breast pump for convenience reasons. The physician’s statement of medical necessity noted only that the breast pump was to be used for frequent expression of breast milk.

争端

Is the Employer required to provide benefits for the Employee’s spouse’s purchase of a breast pump?

双方立场

Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s purchase of a breast pump because it is considered durable medical equipment and should be covered under the terms of the Employer Benefit Plan. 另外, the Employee’s spouse’s physician prescribed the breast pump, therefore it should be considered medically necessary.

Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s purchase of a breast pump since it is primarily used for convenience and not for a medical condition. 此外, the physician’s statement does not contain any information regarding the medical necessity for the breast pump. The provider’s billing indicates that the Employee’s spouse stated that she desired the pump be purchased rather than rented because she would be having additional children so that in the long run it would be cheaper for the Employer to purchase the pump.

相关的规定

第三条. A. (6) (d) of the 1984 Employer 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.

问和答81-38在相关部分指出:

主题: 医疗设备和用品

引用:修改1950 & 1974 Benefit Plans and Trusts, 第三条, Sections A (6) (d) and (e), and A (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, 提供租金和福利, 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 (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, (d)适合在家中使用. 包括DME项目的例子是手杖, commodes and other safety bathroom equipment, 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.

C. Items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or use are not covered benefits. Examples of such items are: ordinary support (panty] hose, 吊袜腰带, 一次性纸杯或毛巾, 棉花球, 棉签, 急救绷带, 运动器材, 脚垫用于拇囊炎或老茧.

讨论

第三条. A. (6) (d) of the Employer 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, (d)适合在家中使用.” An electric breast pump meets these requirements. Whether the equipment in question is medically necessary for the treatment of an illness or injury is determined by the particular circumstances of each case.

在这个例子中, the Employee was told prior to the purchase of the breast pump that it would not be eligible for benefits because it was primarily a convenience item. The physician’s statement of medical necessity only stated that the pump would be used for frequent expressions of breast milk. The physician also stated that the Employee’s spouse had requested the pump for convenience reasons.

In ROD 84-537 (copy enclosed herein) the Trustees concluded that an electric breast pump was not a covered benefit, noting that breast milk could have been collected using a less costly manual pump or by manual expression. 因此, 在这种情况下, the Trustees conclude that the Employer is not required to provide benefits for the purchase of the breast pump.

受托人的意见

The Employer is not required to provide benefits for the purchase of a breast pump for use by the Employee’s spouse.