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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 206, May 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 the provision of vision 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 wife purchased a new pair of eyeglasses under the vision care program. The spouse’s ophthalmologist submitted the prescriptions of her old and new lenses. The Employer denied the charges for the lenses, stating that the prescription limitation had not been met. Charges for the vision examination and frames were paid.
Dispute
Is the Employer responsible for payment of charges related to the lenses for the Employee’s wife?
Position of the Parties
Employee: The Employer should pay for the lenses because the Employee’s wife had not previously purchased a pair of eyeglasses under the vision care program.
Employer: In order for payment to be made for the Employer’s wife’s lenses, the prescription limitation must be met. The spouse’s ophthalmologist provided the prescriptions of the old and new lenses and her new prescription did not differ enough from her most recent one to satisfy the prescription limitation.
Pertinent Provisions
• Article III, Section C (2) of the Employer’s Plan provides as follows:
(2) Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lenses must improve visual acuity by at least one line on the standard chart.
Discussion
The Employer’s Plan does not allow benefit coverage for lenses unless a prescription limitation is met. This limitation provides that a new lens prescription must differ from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change. The Employee’s spouse’s new prescription did not meet this requirement. Therefore, benefits cannot be provided.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for the payment of charges related to the lenses for the Employee’s wife.