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OPINION OF TRUSTEES
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In Re
Complainants: Employee
Respondent: Employer
ROD Case No: 81-398 – January 31, 1984
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 benefits for durable medical equipment under the terms, of the Employer’s Benefit Plan and hereby render their opinion on the matter.
Background
The Employee is an active mine worker eligible for health benefits under the Employer’s Plan. The Employee’s dependent son has anhidrotic ectodermal dysplasia, a disorder of the sweat glands, which prevents him from adequately controlling his body temperature. This disorder can be life threatening in extreme temperatures. The child’s attending physician has prescribed a room air conditioner for his use in the home to prevent overheating of his body. The Employer has denied payment of the charges for the air conditioner.
Dispute
Is the Employer responsible for payment of the charges for an air conditioner for the Employee’s son’s use?
Position of the Parties
Position of the Employee: The Employee believes that, because of the circumstances in this case, the air conditioner should be a covered benefit for his son.
Position of the Employer: The Employer maintains that an air conditioner’s primary and customary use is non-medical and that, because it is an environmental control device, it would be useful in the absence of an illness or injury. The Employer, therefore, contends that an air conditioning unit cannot be considered durable medical equipment for which benefits are to be provided.
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.
Q&A 81 – 38 provides in part as follows:
Subject: Medical Equipment and Supplies.
Question: What medical equipment and supplies are covered under the Plan?
Answer:
A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service 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. Examples of covered DME 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.
Discussion
Q & A 81-38 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 air conditioner at issue in this case can withstand use, is appropriate for use in the home, and may provide the Employee’s son with 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 disorder. 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, Trustee Combs dissenting, are of the opinion that the Employer is not responsible for payment of the charges for the purchase of an air conditioner for the Employee’s son’s use.