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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-148 – August 2, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 exercise equipment under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner had a total knee replacement of the right knee and has had open heart surgery. His physician prescribed an exercise bicycle for his home use to exercise his right knee, strengthen his lower extremities, and improve his cardiovascular condition.
The Employer denied benefits for the exercise bicycle.
Dispute
Is the Employer required to provide benefits for the exercise bicycle prescribed for the Pensioner?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the exercise bicycle because it is medically necessary for the Pensioner to exercise his right knee and his cardiovascular system.
Position of the Employer: The Employer is not required to provide benefits for the exercise bicycle because exercise equipment is specifically excluded under Article III. A. (11) (a) 23. of the Employer Benefit Plan.
Pertinent Provisions
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 III. 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
Discussion
Article III. A. (6)(d) of the Employer Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.
In this case, the physician prescribed the exercise bicycle so that the Pensioner could exercise the right knee, strengthen his lower extremities, and improve his cardiovascular system. The exercise bicycle is a non-medical item that does not require professional judgment, recommendations, or instructions to purchase or use. According to Q&A 81-38 (copy enclosed herein) such items are considered convenience items and do not qualify as durable medical equipment under the Employer Benefit Plan. Furthermore, Article III. A. (11) (a) 23. specifically excludes exercise equipment from coverage. Therefore, the exercise bicycle is specifically excluded from coverage under the Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the exercise bicycle prescribed for the Pensioner.