OPINION OF TRUSTEES
ROD Case No: 84-219 – May 27, 1987
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 Marine 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 benefits for a seat lift chair under the Employer Benefit Plan.
The Pensioner is being treated for hypertension, arteriosclerotic heart disease, obesity, gout, rheumatoid arthritis and severe osteoarthritis of the hips, knees and ankles. The arthritis has impaired his physical mobility to the extent that he requires assistance to stand and ambulate. As part of the treatment program, his physician prescribed a seat lift chair (more commonly referred to as a “seat lift”) for the purpose of preventing chair confinement and improving ambulation, hoping to thereby retard further deterioration of his condition. The Employer’s insurance carrier denied payment of benefits on the grounds that seat lifts are not covered items of durable medical equipment.
The Pensioner is also requesting payment of benefits for a walker prescribed by the physician. The Plan Administrator states that the claim for this has not been received; consequently, he has made no determination in this matter.
Is the Employer responsible for payment of benefits for a seat lift chair for the Pensioner?
Positions of the Parties
Position of the Pensioner: The Employer is responsible for payment of benefits for the seat lift chair because it is medically necessary and appropriate for treatment of the Pensioner’s condition.
Position of the Employer: The Employer is not responsible for payment of Benefits for the seat lift chair because seat lift chairs are not covered items of durable medical equipment as they are not primarily and customarily used to serve a medical purpose and they are generally useful to a person in the absence of an illness or injury. In addition, the Employer contends that the use of a seat lift chair in this case will not prevent deterioration of the Pensioner’s condition.
Article III A. (6) (d) of the 1984 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 and A #81-38 states:
Subject: Medical Equipment and Supplies
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (d) and (e), and A (7) (a) and (d)
What medical equipment and supplies are covered under the Plan?
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).
Article III A. (6)(d) of the Employer Benefit Plan provides benefits for 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-i.e., 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 of injury that causes impairment of mobility. Fourth, the seat lift can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
In ROD 84-135 (copy enclosed), the Trustees found that the medical necessity for the seat lift prescribed had been established in that particular case. Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6)(d) of the Employer Benefit Plan only if it is medically necessary for the treatment of an illness or injury. In this case, the prescribing physician states that the seat lift will allow the Pensioner to transfer from the chair, ambulate and do more for himself and that the seat lift chair will improve and/or retard deterioration of the Pensioner’s condition, yet he has not demonstrated specifically how this will occur. After reviewing the available information obtained from the prescribing physician, a Funds’ medical consultant is of the opinion that neither the prescribing physician nor the Pensioner has demonstrated that the use of the seat lift chair will prevent chair confinement or prevent deterioration of the Pensioner’s condition, and that the medical necessity for the seat lift chair has not been established. Since medical necessity has not been established in this case the Employer is not responsible for providing benefits coverage for the seat lift chair.
The Trustees are unable to address the provision of benefits for the walker until the Plan Administrator has made a final determination concerning its coverage.
Opinion of the Trustees
The Employer is not responsible for payment of benefits for a seat lift chair for the Pensioner.