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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-135 – September 30, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Nine Workers of America (“UMWA”) 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 health benefits coverage for the rental of a seat lift chair under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was being treated for osteoarthritis of both knees and cancer of the lung which had spread to the brain. As part of the treatment program the physician prescribed a seat lift chair (more commonly referred to as a “seat lift”) to prevent bed or wheelchair confinement, minimize the patient’s disability and allow her to function to the maximum of her capacity.
The seat lift was prescribed on February 6, 1985 and supplied on a monthly rental basis until the patient’s death on July 19, 1985. The Employer paid the charges for the first month’s rental but denied charges for the subsequent five months. No explanation was offered as to the reason the first month’s rental was paid.
Dispute
Is the Employer responsible for paying benefits for the rental of a seat lift?
Positions of the Parties
Position of the Employee: The Employer is responsible for paying benefits for the seat lift, because it was medically necessary and appropriate for treatment of the Employee’s spouse’s condition.
Position of the Employer: The Employer is not responsible for paying benefits for the seat lift because seat lifts are convenience items and are not therapeutically effective in the treatment of osteoarthritis of the knees.
Pertinent Provisions
Article III A (8) (d) of the Employer Benefit Plan states:
(d) Medical Equipment
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states:
Subject: Medical Equipment and Supplies
References:Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (5) (d) and (e), and A (7) (a) and (d)
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.
2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue pads”), 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
Article III. A. (6)(d) of the Employer Benefit Plan provides coverage for the rental of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&A 81-38 states that covered equipment includes, “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.” The seat lift chair rented for the Employee’s spouse meets all four criteria. First, it can withstand repeated use. Second, a seat lift is primarily and customarily used for a medical purpose, that is, to assist mobility impaired persons to sit and stand. Third, the lift function of the chair would not be necessary for persons who do not have an illness or injury that causes an impairment of mobility. Fourth, the seat lift can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (8)(d) of the Employer Benefit Plan only if a physician determines that it is medically necessary for the treatment of an illness or injury. Three of the Employee’s spouse’s physicians have stated that she had arthritis of both knees. The condition was of such severity that it was treated with both oral medication and injections into the knee joints. The prescribing physician stated on the Certificate of Medical Necessity that the seat lift was medically necessary and that it was needed to prevent bed or wheelchair confinement. Furthermore, the orthopedic physician stated in his letter of October 30, 1985 that the seat lift chair was necessary to alleviate pain. Therefore, the seat lift was medically necessary for the treatment of the Employee’s spouse’s arthritis.
The seat lift that was rented for the Employee’s spouse was an item of durable medical equipment suitable for home use and was determined by a physician to be medically necessary; therefore, it is a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for providing benefits for the seat lift used by the Employee’s spouse from February 8, 1985 through July 19, 1985.