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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-046 – October 26, 1988
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 under the terms of the Employer Benefit Plan.
Background Facts
A physician whose practice is limited to allergy and immunology has recommended that the Employee purchase a HEPA filter air purifier to use in the child’s bedroom to help control his allergic symptoms. The Employee contends that the Employer is responsible for providing benefits for the HEPA filter air purifier because it is necessary for the child to breathe properly.
The Employer denied coverage for the purchase of the HEPA filter air purifier because it is an environmental control device that would be beneficial to the child even in the absence of the allergy condition.
Dispute
Is the Employer responsible for the payment of charges for the purchase of the HEPA filter air purifier?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of charges for the purchase of the HEPA filter air purifier because it is necessary for the treatment of his son’s allergic symptoms.
Position of the Employer: The Employer is not responsible for the payment of charges for the purchase of the HEPA filter air purifier because it is an environmental control device that would be beneficial to the child in the absence of the allergy condition; therefore, the air purifier is not a covered expense under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (6)(d) of the Employer Benefit Plan provides:
(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.
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.
In RODS 178, 304 and 84-155, the Trustees have addressed the question of coverage for purchase of air filters to relieve the symptoms of allergies. The opinion of the Trustees in those respective cases was that the air filters in question were environmental control devices that were not primarily medical in nature and that would be useful to the Complainants in the absence of their allergies. The Trustees concluded in those cases that such devices cannot be considered durable medical equipment for which benefits are provided under Article III. A. (6)(d).
Similarly, because the HEPA filter air purifier in this case is an environmental control device, it would be useful to the Employee’s son in the absence of his allergies. Therefore, it is not medical equipment which is covered under Article III. A. (6)(d).
Opinion of Trustees
The Employer is not responsible for payment of the charges for the purchase of the HEPA filter air purifier.