OPINION OF TRUSTEES
ROD Case No. 98, March 25, 1980
Board of Trustees: Harrison Combs, Sr., Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article IX of the United Mine Workers of America 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 level of health benefits for the Employee and hereby render their opinion on the matter.
Complainant is an active mine worker eligible for health benefits under the Employer’s Plan. The Employee was hospitalized for the surgical implantation of an inflatable penile prosthesis. The physician who referred the Employee for treatment stated that the Employee was recommended for this surgery due to impotency which was a secondary condition to the patient’s long standing diabetes mellitus. The Insurance Carrier denied payment of the hospitalization and surgical charges on the basis that it is not a specific benefit nor was there evidence that the operation and implant were medically necessary.
Question or Dispute
Are the charges associated with the implant of the inflatable penile prosthesis a covered benefit?
Position of Parties
Complainant: The Insurance Company is responsible for the payment of the medical services.
Respondent; The Insurance Company is not responsible for coverage because 1) there is no evidence that the operation was “medically necessary” and 2) the prosthetic device is not specifically listed in Article III, Section A(7)(a) Orthopedic and Prosthetic Devices of the Employer’s Plan. By virtue of Article III, Section A(10) (a)(25) General Exclusions, those types of services not specifically provided by the Plan are excluded from coverage.
o Article III, Section (7)(a) Orthopedic and Prosthetic Devices provides:
“Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary. The following types of equipment are covered:
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, arms, legs and ostomy bags and supplies.”
o Article III, Section (3)(a) Surgical Benefits provides:
“Benefits are provided for surgical services essential to a Beneficiary’s care consisting of operative and cutting procedures … for the treatment of illnesses, injuries, fractures or dislocations, which are performed either in or out of a hospital by a physician.”
The provisions of the Plan do not specifically exclude the provision of such treatment per se. According to our medical consultants, impotence in diabetic males is extremely frequent. In view of the fact that the impotency in this case results from or occurs concomitantly with a related illness (i.e., diabetes mellitus), it might be appropriate to provide coverage for this condition when treatment is recommended and rendered by a physician. It is clear from the plan language that treatment for diabetes mellitus is a covered benefit. In this case the impotency is a secondary condition to longstanding diabetes. Therefore treatment related to this secondary condition should be a covered benefit.
The past practice under the provisions of the 1974 Coal Wage Agreement was to provide benefits for a penile prosthesis and its insertion under the following circumstances:
1. If surgery was recommended and performed by a surgical specialist; and
2. If impotency was due to a medical condition, rather than a psychological condition.
The Trustees are of the opinion that the Insurance Carrier is required to provide benefits for the surgery and hospitalization related to the implantation of a penile prosthesis.