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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-231 – October 29, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustees; William B. Jordan, Trustee; William Miller, Trustee; Donald R. 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 the provision of benefits for corrective lenses under the Employer Benefit Plan.
Background Facts
The Pensioner’s spouse is being treated for age-related macular degeneration, a condition affecting the structure of the retina and causing progressive deterioration in visual acuity. An effect of the condition is that people who suffer from it usually require frequent changes in their corrective lenses in order to restore visual acuity as the condition progresses. In October 1985, the Pensioner’s spouse received new corrective lenses for which vision care benefits were paid by the Employer. In March 1986, the Pensioner’s spouse telephoned the Employer’s insurance carrier to determine whether vision care benefits would be paid for new corrective lenses which were needed because of her condition. After consulting with the Employer, the insurance carrier notified the Pensioner’s spouse that benefits would not be paid because of the Employer Benefit Plan’s provision that vision care benefits are available once each 24-month period. The Pensioner did not submit a claim for vision care benefits but instead filed a request for Resolution of Dispute. The Employer informed the Funds that no claim has been filed for vision care benefits but that, if one were to be filed, it would be denied because of the 24-month provision of the Plan.
Dispute
Is the Employer responsible for payment of benefits for corrective lenses for the Pensioner’s spouse?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of benefits for lenses for the Pensioner’s spouse because the need for frequent changes in her corrective lenses is caused by macular degeneration, medical condition. Case No. 84-231
Position of the Employer: The Employer is not responsible for payment of benefits for corrective lenses for the Pensioner’s spouse because of the Plan’s 24-month frequency limitation.
Pertinent Provisions
Article III. A. (9)(a) of the Employer Benefit Plan states:
(9) Vision Care Program
(a) Benefits Maximum Account Frequency Limits
Vision Examination $20 Once every 24 months
Per Lens (Maximum – 2) Once every 24 months
– Single Vision 10
– Bifocal 15
– Trifocal 20
– Lenticular 25
– Contact 15
Frames 14 Once every 24 months
Article III. A. (11) (a) 22. of the Employer Benefit Plan states:
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
22. Eyeglasses or lenses, except when medically required because of surgically caused refractive errors or as otherwise provided in Section A. (9).
Discussion
Under the vision care provision of the Employer Benefit Plan, benefits are provided for corrective lenses once every 24 months. Benefits may be provided more frequently only if new lenses are medically required as a result of surgically caused refractive error. The Pensioner’s spouse requires frequent changes to her corrective lenses due to macular degeneration and not as the result of a surgically caused error. Her new lenses are therefore covered benefits only once every 24 months.
Opinion of the Trustees
The Employer is not responsible for the payment of benefits for corrective lenses for the Pensioner’s spouse more than once every 24 months.