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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-270 – April 28, 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 a motorized chair under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse is being treated for chronic rheumatoid arthritis. Her condition has deteriorated to the point that her range of independent ambulation is very limited. The effects of the condition include weakening of her wrists and hands, so that she cannot use a manual wheelchair. Her physician prescribed a motorized three-wheel chair (sometimes referred to as a “scooter chair”) for her use. According to her physician and to a consultant rheumatology specialist engaged by the Employer to examine the Employee’s spouse, she would essentially be housebound without the motorized chair. The Employer has denied coverage for the motorized chair on the grounds that it is not medically necessary.
Dispute
Is the Employer responsible for providing benefits for the motorized chair?
Position of the Parties
Position of the Employee: The Employer is responsible for paying benefits for the motorized chair because it is medically necessary for the Employee’s spouse’s crippling arthritic condition, and it would improve her psychological condition.
Position of the Respondent: The Employer is not responsible for paying benefits for the motorized chair because it would only be used outside the home (e.g., to go shopping and for family outings) and would therefore be considered a convenience item rather than a piece of medically necessary equipment which could be covered under Plan provisions.
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
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.
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 Ill, Section A (6) (e).
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 an 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.
A consulting physician’s report indicates that during examination the Employee’s spouse was able to ambulate a distance of 20 feet without assistance. A three wheel motorized chair, therefore, is not medically necessary for her use. The purpose for the device would be to enable the Employee’s spouse to leave the household for nonessential activities. Therefore the three wheel motorized chair in this case would serve as a convenience item and would not be medically necessary. As such it is not a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing benefits for the motorized chair to be used by the Employee’s spouse.