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OPINION OF THE TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-170 – May 28, 1986

Board of the 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 American (“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 for visual therapy under the terms of the Employer Benefit Plan.

Background Facts

An optometrist treated the Employee’s son for a congenital eye problem which was causing difficulties with eye-hand coordination, gross and fine motor coordination, headaches and upset stomach. Treatment by the optometrist consisted of visual therapy sessions. After eighteen sessions, improvement was noted in eye-hand coordination, eye movements, reading, depth and perception, headaches and stomach upset. Additional sessions were planned to further improve eye movements. The Employer denied payment for the visual therapy.

Question or Dispute

Is the Employer responsible for the provision of health benefits for the visual therapy provided to the Employee’s son?

Position of the Parties

Position of the Employee: The Employer is responsible for the provision of health benefits for the visual therapy provided to the Employee’s son under the medical portion of the Employer Benefit Plan because the therapy corrected problems other than vision.

Position of the Employer: The Employer is not responsible for the provision of health benefits for the visual therapy provided to the Employee’s son because it is specifically excluded from coverage under the Employer Benefit Plan.

Pertinent Provisions

Article III. A. (9) (c) 4 of the Employer Benefit Plan states:

(9) Vision Care Program

(c) Exclusions include:

4. special procedures, such as orthoptics, vision training, subnormal vision aids, aniseikonic lenses and tonography;

Article III. A. (11) (a) 27 of the Employer Benefit Plan states:

(11) General Exclusions

(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

27. Any types of services, supplies or treatments not specifically provided by the Plan.

Discussion

According to Article III. A. (9) (c) 4 of the Employer Benefit Plan vision training, or visual therapy, is specifically excluded from coverage under the vision care program of the Plan.

The Employee contends that because the visual therapy corrected problems other than vision, it is a covered benefit under the medical portion of the Employer Benefit Plan. The medical portion of the Plan, however, contains no provision for visual therapy, although it does specifically provide benefits for other types of therapy (i.e., physical and speech). According to Article III. A. (11) (a) 27 of the Employer Benefit Plan, any services not specifically provided by the Plan are excluded from coverage. By virtue of the fact that it does not provide benefits for visual therapy, the Plan excludes such benefits from coverage.

Opinion of the Trustees

The Employer is not responsible for the provision of health benefits for the visual therapy provided to the Employee’s son.