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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 233 July 28, 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 an elevator lift and hereby render their opinion on the matter.
Background Facts
The Employee is an active mineworker eligible for health benefit coverage under the Employer’s Plan. The Employee’s spouse suffers from end stage renal disease for which she receives chronic hemodialysis treatment three times a week. The Employee has requested the purchase of an elevator lift for the stairs to facilitate his spouse’s transit from their garage to their house upon return from the dialysis treatments. The attending physician signed a Statement of Medical Necessity, which states the reason the equipment is medically necessary as “patient is receiving chronic hemodialysis – chronic weakness in legs and cannot negotiate steps (patient home does not allow for confinement to one floor)”.
Dispute
Is the Employer required to provide health benefit coverage for an elevator lift for the Employee’s spouse?
Position of the Parties
Position of the Employee: The Employee states that the Employer should pay for a stair lift because ‘it is required by her (spouse) doctor because climbing the stairs is a hazard to her and to me”. Additionally, this is not a luxury item, but one which is necessary because of a permanent medical condition.
Position of Employer: The Employer states that although there is no doubt as to the seriousness of the medical problem, an elevator lift is not considered to be an item of medical equipment for which benefits can be provided under the Employer’s Plan.
Pertinent Provisions
• Article III, Section 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 Q & A #49, approved by the Trustees on June 20, 1978, provides in part, as follows:
Subject: Medical Equipment and Supplies
References:Article III, Section A (6)(d), (e) and (7)(a), (d) of the Employer’s Plan and 1978 Contract Q & A #29.
Question:
What medical equipment and supplies are covered under the 1978 Agreement?
Answer:
A. 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 U.M.E. items are: canes, commodes, and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames, and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers, and wheel chairs.
2. Supplies necessary to maintain home-bound or bed-ridden beneficiaries. Examples of covered supplies are: enema supplies, disposable sheets and pads (also called “Chux” or “blue pads”), special mattress drainage systems and associated supplies for home management of open or draining wounds, heating pads (for therapeutic use only) and insulin needles and syringes.
3. Oxygen, as specified in Article III, Section A (6)(e).
Discussion
Benefits are provided under Article III A 6 (d) of the Employer’s Plan only for medical equipment suitable for home use and only when a physician determines that the equipment is medically necessary. The Employee’s spouse’s physician has stated that an elevator lift is medically necessary. Therefore, the only question is whether the elevator lift is medical equipment suitable for home use.
1978 Contract Q & A #49 states that benefits are provided for the rental or purchase of medical equipment can 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 elevator lift in this case can withstand use and is appropriate for use in the home, it is not primarily and customarily used to serve a medical purpose. Additionally, such an item would generally be useful in the absence of an illness or injury. Therefore, it can not be considered medical equipment for which benefits can be provided.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not required to provide health benefit coverage for the elevator lift for the Employee’s spouse.