OPINION OF TRUSTEES
ROD Case No: 84-288 – 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 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 out-of-area transportation, exercise equipment, and an electronic air cleaner under the terms of the Employer Benefit Plan.
The Employee was referred out-of-area to the Mayo Clinic in Rochester, Minnesota for an evaluation of chronic pain associated with tension vascular headaches and of related chemical dependency which had been unsuccessfully treated locally. Once he was found to be a suitable candidate for treatment at the Mayo Clinic, he returned for a month’s admission in the clinic’s chemical dependency program. Subsequently, the Employee returned to Rochester to participate in Mayo Clinic’s pain management program at St. Mary’s Hospital. The chemical dependency and pain management programs both involved family counseling, so the Employee’s spouse made two trips from the family residence in Utica, Kentucky to Rochester, Minnesota and back. In addition to transportation expenses, the Employee and his spouse incurred expenses for lodging and meals. After completion of the pain management program, an exercise bike and two sets of sand bag weights were prescribed for the Employee’s home use in maintaining his pain management regimen.
In an unrelated treatment, the Employee’s daughter was seen by the family doctor for allergy problems, and an electronic air cleaner was prescribed for her use.
Payment of benefits for all of the incurred expenses described above has been denied by the Employer.
Is the Employer responsible for the provision of benefits for transportation and lodging for the Employee and his spouse, for an exercise bicycle and sand bag weights for the Employee, and for an electronic air cleaner for the Employee’s daughter?
Positions of the Parties
Position of the Employee: The Employer is responsible for provision of benefit for the transportation and lodging and the items of equipment, as these are all covered services under the Plan.
Position of the Employer: The Employer is not responsible for the provision of benefits for lodging and transportation as the medical care could have been received closer to the beneficiary’s home and prior approval was not requested. In addition, the Employer is not responsible for providing benefits for the exercise equipment for the Employee or for the electronic air cleaner for the Employee’s daughter because those items of equipment are not covered under the Plan.
Article III. A. (7)(e) of the Employer Benefit Plan states:
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a hospital, clinic, medical center, physician’s office, or skilled nursing care facility, when considered medically necessary by a physician.
With prior approval from the Plan Administrator benefits will be also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out-of-area medical center.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or clinic for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
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.
Article Ill. A. (11) (a) 23. of the Employer Benefit Plan states in part:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
23. Exercise equipment
27. Any types of services, supplies or treatments not specifically provided by the Plan.
Benefits for transportation expenses to an out-of-area medical center are provided for the beneficiary if the needed medical care is not available near the beneficiary’s home. Benefits are also provided for travel expenses for an escort if the beneficiary requires one during transportation. These benefits are provided when prior approval has been obtained from the Plan Administrator. In the present case, benefits were provided for the care received and for the initial travel to obtain the evaluation. The Plan Administrator has denied subsequent coverage for travel and lodging costs for the Employee and his wife based on the position that similar care could have been obtained at a closer facility and that prior approval for the trips to Rochester, Minnesota was neither sought nor granted. There are several drug dependency treatment programs closer to Utica, Kentucky than the Mayo Clinic, and there are two pain management programs, in Indianapolis, Indiana and Nashville, Tennessee, that are closer than Rochester, Minnesota.
The Complainant has asked how he would know which facilities are covered and which are not. The requirements to obtain prior approval have been established to address such an issue. The only provision for accompanied travel in the Plan is for an escort when the physician submits a satisfactory justification for the need. In this case, the participation of the spouse in the therapy process is not a specifically stated benefit under the Plan and therefore is not covered.
Exercise equipment has been addressed by the Trustees in Q&A 81-38 (copy enclosed herein); items such as the bicycle and the sand bags are convenience items. Although unrelated to the Complainant’s treatment, the same is true of his dependent’s electronic air filter. In ROD 178 (copy enclosed herein), the Trustees have found such an item to be of a convenience nature.
Opinion of the Trustees
The Employer is not responsible for the provision of benefits coverage for the travel and lodging expenses incurred by the Employee and his wife, for the exercise equipment, or for the electronic air filter for the Employee’s dependent.