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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-155 – June 20, 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 Mine 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 health benefits coverage for durable medical equipment.
Background Facts
A pediatric allergist has treated the Employee’s eight year old daughter since April 1985 for allergies to pollens, dusts, dust mites and molds for which she is presently receiving desensitization injections. In addition to allergies, the Employee’s daughter has been treated for bronchial asthma and has a history of sudden rapid heartbeat (paroxysmal atrial tachycardia), which limits the use of the usual allergy medications. The daughter’s mother states that exposure to allergens frequently precipitates her daughter’s tachycardia.
The allergist has recommended purchase of a hepa filter air purifier for home and school use to reduce her allergen exposure as much as possible. He has given permission to excuse her from physical education, outdoor activities and physical exertion at school since she is intolerant to exercise and outdoor exposure. Her physician states her allergy symptoms of wheezing, nasal congestion and headaches have reduced significantly since implementing the hepa filter air purifier. The Employer has denied coverage for this purchase.
Dispute
Is the Employer responsible for the payment of charges for the purchase of the hepa filter air purifier?
Position of the Parties
Position of the Employee: The Employer is responsible for the payment of charges for the purchase of the hepa filter air purifier because use of this equipment is primarily and customarily for medical reasons.
Position of the Employer: The Employer is not responsible for the payment of charges for the purchase of the hepa filter air purifier because, as an environmental control device, its primary and customary use is non-medical.
Pertinent Provisions
Article III. A.(6) (d) of the 1984 Employer Benefit Plan provides:
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 states:
Subject: Medical Equipment and Supplies
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III. Section A. (6) (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.
Discussion
Under Article III, A. (6) (d) of the Employer Benefit Plan, benefits are provided for medical equipment. The type of medical equipment which is covered is further defined by Q&A 81-38, which states that covered 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.
In RODs No. 178 and 304, the Trustees have addressed the question of coverage for purchase of air filters to relieve the symptoms of allergies. The opinion of the Trustees in those respective cases was that the air filters in question were environmental control devices and therefore not medical equipment which is otherwise covered under Article III. A. (6) (d). In addition, the equipment in question was determined to be not primarily medical in nature and to be useful to the Complainants in the absence of their allergies.
Similarly, the hepa filter air purifier would be useful to the Employee’s daughter in the absence of her allergies. It is an environmental control device and is not primarily and customarily used for a medical purpose, and therefore is not medical equipment which is covered under Article III. A. (6) (d).
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment of the charges for the purchase of the hepa filter air purifier.