OPINION OF TRUSTEES
Complainant: Disabled Employee
ROD Case No: 88-338 – March 26, 1991
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 a mattress and recliner for a disabled Employee under the terms of the Employer Benefit Plan.
The Employee suffered a cerebral vascular accident (stroke) and is, consequently, partially paralyzed on his left side. He also has perceptual and cognitive deficits causing poor balance and a tendency to fall or drop things. The Employee’s physician previously prescribed a manual wheelchair, for which the Employer has provided benefits. The Employee has stated that the wheelchair does not provide proper support and, according to his spouse, the wheelchair does not allow enough maneuverability to be used’ at home. Consequently, the Employee’s physician thereafter prescribed a multi-position recliner and a queen size mattress with numerous pillows. The physician states that because of his condition and the brace on his left leg, the Employee needs this type of recliner for support when sitting and to be able to get up from a chair for ambulation. The physician prescribed the queen size bed as necessary to provide extra room for proper positioning and for support of the Employee’s left side with numerous pillows.
The Employer denied benefits for the purchase of the recliner and mattress.
Is the Employer required to provide benefits for the recliner and mattress prescribed by the Employee’s physician?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the recliner and mattress because these items are necessary to provide proper support for the Employee when sitting and lying down due to his medical condition.
Position of the Employer: The Employer is not required to provide benefits for the recliner and mattress because neither item meets the definition of durable medical equipment under the Plan.
Article III. A. (6)(d) of the Employer Benefit Plan states:
(6) Home Health Services and Equipment
(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. (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. Q&A 81-38 (copy enclosed herein) states that covered medical equipment is that which (a) can withstand use (i.e., could normally be rented), (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 this case, the disabled Employee’s physician has prescribed a queen size mattress and recliner for the Employee’s use. A queen size mattress cannot normally be rented and is not primarily and customarily used to serve a medical purpose. In addition, it is an item useful to people in the absence of an Illness or injury. Therefore, the mattress does not meet the definition of medical equipment that may be covered under the Plan. Accordingly, the Employer is not required to provide benefits for this mattress.
In contrast, the type of recliner recommended and purchased for the Employee in this case meets the criteria for durable medical equipment. First, it can withstand repeated use. Second, this type of recliner, which is often referred to as a rollabout chair, is primarily and customarily used in various patient care settings to assist mobility-impaired persons. Third, this chair would not be useful for persons who do not have an illness or injury that causes an impairment of mobility. Fourth, this chair can be safely operated without the assistance of professional personnel and is, therefore, suitable for home use.
Although an item of durable medical equipment meets the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6)(d) of the Employer Benefit Plan only if it is medically necessary for the treatment of an illness or injury. A Funds’ medical consultant has reviewed the information provided in this case and has advised that the disabled Employee suffers from left-sided paralysis that will not improve with time and that has left him essentially confined to a chair. The consultant has advised that, due to his impaired mobility, the disabled Employee has prolonged periods of sitting and needs better support than that which is provided by the wheelchair which was previously prescribed and for which the Employer provided benefits. The medical consultant has advised that the type of recliner prescribed in this case is medically necessary for the Employee’s home use instead of a wheelchair. Because the recliner prescribed for the disabled Employee is a medically necessary item of durable medical equipment suitable for home use, the Employer is required to provide benefits for the recliner under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the queen size mattress prescribed for the Employee. However, the Employer is required to provide benefits for the prescribed recliner which, in this situation, is more appropriate for the Employee’s home use than a wheelchair.