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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 178, March 26, 1981
Board of Trustees: Harrison Combs, 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 durable medical equipment benefits and hereby render their opinion on the matter.
Background Facts
The Employee is an active mineworker eligible for health benefits under the Employer’s Plan. The Employee’s dependent son has an acute allergy to various kinds of dust, molds, grasses, and trees. The child’s attending physician prescribed the purchase of an electrostatic precipitator, a dust removal apparatus, for home use. The Employer has denied payment of the charges for this purchase.
Dispute
Is the Employer responsible for the payment of charges for the purchase of an electrostatic precipitator?
Position of the Parties
Position of the Employee: The Employee is questioning the allowable coverage of such equipment. He states that the device is used in one room and is of no benefit to anyone other than his son.
Position of the Employer: The Employer states that the dust removal apparatus, or electric air cleaner, is not a covered expense as indicated in Article III, a (6)(d) of the Employer’s Plan, which provides: “Benefits are provided for rental, or where appropriate, purchase of medical equipment suitable for home use when determined to be necessary by a physician”. This position is supported by 1978 Contract Q & A #49 which states, in part, that benefits are provided for durable medical equipment, which generally is not useful to a person in the absence of an illness or injury. This air cleaner would be beneficial to the child even in the absence of the allergy condition. Additionally, the Employer’s Insurance Carrier’s Group Policy specifically excludes electric air cleaners as non-medical in nature. Based on the above information, the electric air cleaner was denied.
Pertinent Provisions
• Article III A 6(d) of the Employer’s Plan provides as follows:
Benefits are provided for rental, or where appropriate, purchase of medical equipment suitable for home use when determined to be necessary by a physician.
• 1978 Contract Question and Answer #49, as approved by the Trustees on June 20, 1978 provides, in part, as follows:
Subject: Medical Equipment and Supplies
Question: What medical equipment and supplies are covered under the 1978 Agreement?
Answer: Under the Home Health Services and Equipment provision, benefits are provided for the rental or purchase of medical equipment and supplies suitable for home use (including items essential to the effective use of the equipment) when determined to be necessary by a physician. These equipment and supplies include, but are not limited to:
1. Durable medical equipment which (a) can withstand use (i.e., could normally be rented), and (b) is primarily and customarily used to serve a medical purpose, and (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, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheelchairs.
Discussion
1978 Contract Q & A #49 states that benefits are provided for the rental or purchase of medical equipment, including, but not limited to, durable medical equipment. Covered durable medical equipment is that which (a) can withstand use; (b) is primarily and customarily used to serve 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. Although the electric air cleaner in this case can withstand use, is appropriate for use in the home, and may purify the air of the child’s room and restore an environment desirable for his condition, its primary and customary use is non-medical. Additionally, because it is used as an environmental control device, it would be useful to the child in the absence of his allergies. Therefore, it cannot be considered durable medical equipment for which benefits are provided. Moreover, as an environmental control device, it is not medical equipment otherwise covered under Article III A. 6(d).
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment of the charges for the purchase of an electrostatic precipitator.