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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-282 – March 3, 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 benefits for contact lenses under the Employer Benefit Plan.
Background Facts
The Employee had a right eye cataract surgically removed in April 1979 and a left eye cataract surgically removed in January 1980. Intraocular lenses were not implanted due to the Employee’s young age (30). The optometrists who have treated the Employee since the cataract removals have prescribed extended-wear soft contact lenses to replace the natural lenses of the Employee’s eyes. The Employer has limited its payment of benefits to a level consistent with the cost of hard contact lenses. The Employee seeks payment of full benefits for extended-wear soft contact lenses.
Dispute
Is the Employer responsible for payment of benefits for extended-wear soft contact lenses for the Employee?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of full benefits for the extended wear soft contact lenses because they are medically necessary.
Position of the Employer: The Employer recognizes that contact lenses are medically necessary. However, hard contact lenses would meet the Employee’s needs. While extended-wear soft contact lenses may be more convenient for the Employee, they are not medically necessary. They are more expensive and require replacement more frequently than hard contact lenses. The Employer has satisfied its responsibility to provide benefits for medically necessary treatment by paying benefits at a level consistent with the cost of hard contact lenses. The incremental increase
in expenses from the cost of hard contact lenses to the cost of extended-wear soft contact lenses would represent benefit payments for convenience items, which are not covered by the Employer Plan.
Pertinent Provisions
The introduction to Article III of the Employer Benefit Plan states in part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
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 Article III A. (11)(a) 22. of the Employer Benefit Plan, eyeglasses or lenses are covered when medically required because of surgically caused refractive errors.
The Employer agrees that contact lenses were medically necessary for the Employee but maintains that the extended-wear soft contact lenses were prescribed for the convenience of the Employee and not for reasons of medical necessity. The Employer asserts that hard contact lenses would serve the same purpose as the extended-wear soft contact lenses and that paying benefits at a level consistent with the cost of hard contact lenses satisfies the Employer’s responsibility to provide benefits for medically necessary services.
Both optometrists who have treated the Employee since her cataract surgeries state that hard contact lenses are contraindicated because the severity of her vision loss would require extremely thick lenses which would be very uncomfortable and probably even impossible for the Employee to wear. Both optometrists assert that soft contact lenses are medically necessary. However, the optometrist currently treating the Employee stated in a telephone discussion with Funds’ clinical staff that the extended-wear feature was prescribed primarily for the convenience of the Employee.
After reviewing the available information, a Funds’ physician consultant has determined that soft contact lenses are medically necessary but that the extended-wear feature is a matter of convenience for the Employee and therefore not medically necessary.
Since contact lenses are provided under the Plan when medically required because of surgically caused refractive error and there is no stipulation that states such contact lenses must be hard rather than soft, the contact lenses that have been determined to be medically necessary (i.e., soft contact lenses) are covered under the Plan. The Employer is therefore responsible for benefits at a level consistent with the cost of soft contact lenses in order to satisfy its responsibility for providing benefits for medically necessary treatment, but is not responsible for benefits for the extended-wear feature.
Opinion of the Trustees
The Employer is responsible for payment of benefits for soft contact lenses and the replacement thereof, but is not responsible for payment of benefits for extended-wear soft contact lenses.