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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-232 – April 30, 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 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 health benefits coverage for an electric wheelchair under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s twelve year old dependent son has Duchenne’s muscular dystrophy, a progressive and debilitating neuromuscular disorder, and is confined to a wheelchair permanently. The natural course of the disease has produced an increasing weakness in the upper extremities which prevents the Employee’s son from utilizing a manual wheelchair independently.
The Employee’s son uses an electric wheelchair at school and is transported to and from school in the electric wheelchair in a specially equipped van. The Employer has denied coverage for the electric wheelchair on the grounds that it is a convenience item.
Dispute
Is the Employer responsible for paying benefits for an electric wheelchair for the Employee’s son?
Positions of the Parties
Position of the Employee: The Employer is responsible for paying benefits for an electric wheel chair because it is medically necessary and appropriate for treatment of the Employee’s son’s condition.
Position of the Employer: The Employer is not responsible for paying benefits for the electric wheel chair because it is a convenience item and is not medically necessary.
Pertinent Provisions
Article III. A. (6) (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
Reference: Amended 1950 & 1974 Benefit Plans & Trusts, Article Ill, 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 the purchase of medical equipment suitable for home use when determined by a physician to be medically necessary. Q&A 81,38 states that covered durable medical equipment is equipment that a) can withstand use, b) is primarily and customarily used to service a medical purpose, c) generally is not useful to a person in the absence of illness or injury, and d) is appropriate for use in the home. Thus, Q&A 81-38 clearly applies only to equipment that is medically necessary for home use.
The Employee’s son is not able to ambulate due to the neurological impairments associated with Duchenne’s muscular dystrophy. Without a wheelchair he does not have sufficient mobility to complete the basic activities of daily living (i.e., bathing, dressing, toileting, feeding, transferring from bed to chair, etc.). Part of the child’s day is spent in school where an electric wheelchair is required for him to function independently, that is, without someone to push his manual wheelchair, the same as is done at home. The Employee’s spouse has stated that the electric chair does not allow enough maneuverability to be used at home. In that environment, the family uses a manual wheelchair to transport and transfer the child. Without a manual wheelchair, the child would be chair or bed-confined while in his home. An electric wheelchair is not practical in the patient’s home. Thus, in this situation, the Employer has correctly denied payment for the electric wheelchair and approved payment for the manual one since the electric wheelchair is not medically necessary for home use.
Opinion of the Trustees
The Employer is not responsible for the provision of benefits coverage for the electric wheelchair for the Employee’s son.