_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-82, November 23, 1982
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 coverage of an insulin infusion pump and hereby render their opinion on the matter.
Background Facts
The Employee’s wife has insulin-dependent diabetes mellitus. She has purchased a subcutaneous insulin infusion pump, The pump is a portable device worn by the patient. The pump provides insulin by constant infusion for basal insulin requirements. The Plan Administrator has denied payment for the pump.
Information provided to the Trustees indicates that the use of a subcutaneous insulin infusion pump is considered to be experimental and, therefore, not a covered benefit under the federal Medicare program. In addition, the use of this device is considered to be experimental by the United States Food and Drug Administration.
Question or Dispute
Is the Employer responsible for payment of charges for the insulin infusion pump?
Position of Parties
Employee: The Employee feels that the charges for the insulin infusion pump are covered because the pump is not a convenience item and is not experimental. It is a life-saving device.
Employer: The Plan Administrator feels that the pump is a convenience item and therefore not covered. The Plan Administrator further contends that there is no provision in the Plan to cover this.
Pertinent Provisions
Article III. A. (11) (a) 24. of the Employer’s Benefit Plan which provides as follows:
(a) In addition to the specific exclusions otherwise contained in
the Plan, benefits are also not provided for the following:
24. Charges for treatment with new technological medical devices and therapy which are experimental in nature.
Discussion
Under Article III. A. (11) (a) 24. of the Employer’s Benefit Plan, benefits are excluded for treatment with new technological medical devices and therapy which is experimental in nature. According to the information available to the Trustees, the use of an insulin infusion pump is still being researched and is considered to be experimental. Therefore, the pump is not a covered benefit under the Employer’s Benefit Plan.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment of charges for the insulin infusion pump.