_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-385 – April 23, 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 an adjustable bed for a Pensioner under the terms of the Employer Benefit Plan.
Background Facts
The Complainant is disabled as a result of a work-related injury sustained while working for the Respondent. He states that his chronic back problems have sometimes required that he use a hospital bed in his home and receive physical therapy. The Complainant purchased an adjustable bed with a heating element and a special massage feature. He contends that the adjustable bed serves the purpose of a hospital bed and alleviates the need for physical therapy. The Complainant’s physician states that the adjustable bed has provided marked relief of the Complainant’s back pain and will enable the Complainant to be more active. The Complainant has asked that the Respondent provide benefits for the purchase of the adjustable bed by paying either the full amount for the bed or an amount equivalent to the cost of a hospital bed, which the Complainant says would otherwise be required.
The Respondent has denied benefits for the adjustable bed purchased by the Complainant.
Dispute
Is the Respondent required to provide benefits for the adjustable bed purchased by the Complainant?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide benefits for the adjustable bed because it provides relief from the Complainant’s back pain, it alleviates the need for physical therapy, and it serves the purpose of a hospital bed, which would otherwise be required for the Complainant’s home use.
Position of the Respondent: The Respondent is not required to provide benefits for the adjustable bed because it would be useful to anyone in the absence of an illness, and it is a comfort or convenience item that is excluded from coverage under the Employer Benefit Plan. In addition, the Respondent is not required to provide benefits equivalent to the cost of a hospital bed for the Complainant because the Complainant is not bedridden and the Complainant’s physician has not prescribed a hospital bed nor established that a hospital bed is medically necessary for treatment of the Complainant’s condition.
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 medically necessary by a physician.
Discussion
Under Article III. A. (6)(d) of the Employer Benefit Plan, benefits are provided for medical equipment suitable for home use when determined by a physician to be medically necessary. Q&A 81-38 (copy enclosed herein) states that covered medical equipment includes Durable Medical Equipment (DME) 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. Q&A 81-38 further stipulates that items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or use are not covered benefits.
There is no indication that the adjustable bed purchased by the Complainant was prescribed by his physician as medically necessary for the treatment of a medical condition. The primary purpose of the type of adjustable bed purchased by the Complainant is not medical in nature. While it may serve a therapeutic benefit for the Complainant, it is generally used for relaxation and comfort purposes in the absence of an illness or injury. Therefore, the adjustable bed in question does not meet the definition of medical equipment which may be covered under the Plan. Accordingly, the Respondent is not required to provide benefits in any amount for the Complainant’s adjustable bed.
Opinion of the Trustees
The adjustable bed purchased by the Complainant is not a covered benefit under the Employer Benefit Plan.