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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-084 – February 14, 1989
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 carpet cleaning and air filter devices under the terms of the Employer Benefit Plan.
Background Facts
A physician, whose practice is limited to allergy and clinical immunology, has been treating the Employee’s spouse for seasonal allergic rhinitis (inflammation of the nose) and seasonal allergic conjunctivitis (inflammation of the eyelid and eye) since 1984. He recommended that she obtain a CMS (Carpet Maintenance System) 1000 and Pureflow Air Treatment System. The Employee’s spouse purchased these devices on June 13, 1988. The Employer denied coverage for the equipment.
Dispute
Is the Employer required to pay for the carpet cleaning and air filter devices?
Positions of the Parties
Position of the Employee: The Employer is required to pay for the carpet cleaning and air filter devices because they are necessary for the treatment of the Employee’s spouse’s allergic condition.
Position of the Employer: The Employer is not required to pay for the carpet cleaning and air filter devices because they are environmental control devices that would be beneficial to the Employee’s spouse in the absence of her allergic condition; consequently, they are not covered under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (6)(d) of the Employer Benefit Plan provides:
(6) Home Health Services & Equipment
(d) Medical Equipment
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 in part:
Subject: Medical Equipment and Supplies
References: Amended 1950 & 1974 Benefit Plans & Trust,
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 when determined to be necessary by a physician. Q&A 81-38 states that covered medical equipment includes, but is not limited to, durable medical equipment (DME) that: (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.
The CMS 1000 is an electrical carpet cleaning device used to remove dust and debris from carpet surfaces. The Pureflow Air Treatment System is an air filter used to filter dust particles from ambient air. This equipment is not covered DME because it is not primarily and customarily used to serve a medical purpose and is generally useful to a person in the absence of an illness or injury.
In addition, because the CMS 1000 and the Pureflow Air Treatment System are general purpose environmental control devices, they are not otherwise covered medical equipment under Article III. A. (6)(d). This decision is consistent with the Trustees’ opinions in ROD Nos. 178, 304, 84-155, and 88-046 (copies enclosed herein).
The Employee states that the equipment was prescribed by a physician and that it will primarily be used for a medical purpose. These facts, however, do not establish that the equipment is covered. The Employee also contends that is is unfair for the Employer to refuse to pay for the equipment when the Employer has paid for such equipment in the past. The fact that the Employer may have paid for such equipment in the past does not mean that the equipment is covered under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The CMS 1000 and the Pureflow Air Treatment System are not covered benefits under the Employer Benefit Plan.