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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-374 – 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 health benefits coverage for durable medical equipment.
Background Facts
The Employee’s spouse has chronic back pain. To help alleviate her muscle spasms, her physician has prescribed a two-headed massager. The Employer has denied provision of benefits for the two-headed massager stating that it does not meet the requirements of covered durable medical equipment.
Dispute
Is the Employer responsible for payment of benefits for the two-headed massager?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of benefits for the two-headed massager because it is medically necessary durable equipment that is used primarily for a medical purpose.
Position of the Employer: The Employer is not responsible for the payment of benefits for the two-headed massager because this type of equipment is not primarily or customarily used to serve a medical purpose and it is useful to a person in the absence of an illness or injury.
Pertinent Provisions
Article III. A. (6) (d) of the 1984 Employer Benefit Plan provides:
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be 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?
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 medical equipment. The type of medical equipment which is covered is further defined by Q&A 81-38, which states that covered medical equipment is that which (a) can withstand use; (b) is primarily and customarily used to serve 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.
For medical equipment to be covered by the Plan, it must not only be deemed medically necessary by a physician but also meet the other definitions of medical equipment which may be covered. The Employee’s spouse’s physician has stated that the two-headed massager is medically necessary for her muscle spasms. However, the two-headed massager is not a piece of equipment that is primarily and customarily used to serve a medical purpose, and it is useful to people in the absence of an illness or injury. Therefore, the massager does not meet the definition of medical equipment which may be covered under the Plan.
A Funds’ medical consultant has reviewed the pertinent data and concurs that the massager does not meet the definition contained in Q&A 81-38. Even though the Employee’s spouse’s physician stated that the massager was medically necessary for the Employee’s spouse’s muscle spasms, the massager is considered a convenience item and therefore is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for payment of charges for the purchase of the two-headed massager prescribed for the Employee’s spouse.