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OPINION OF TRUSTEES
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In Re
Complainant: Surviving Spouse
Respondent: Employer
ROD Case No: 88-430 – December 16, 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 seat lift under the terms of the Employer Benefit Plan.
Background Facts
The Complainant is being treated for severe osteoarthritis of both hips. She is an insulin-dependent diabetic and her vision is impaired as a result of diabetic retinopathy. She previously underwent bladder surgery, has been evaluated for a ruptured disc, and has a history of cancer of the uterus. As part of her treatment program, her physician has prescribed a seat lift chair (more commonly referred to as a “seat lift”). Two additional physicians have stated that the seat lift is necessary to facilitate her mobility. One of the physicians states that improved mobility would in turn help her diabetic status. The Employer has denied benefits for the seat lift.
Dispute
Is the Employer required to provide benefits for the seat lift prescribed for the Complainant?
Positions of the Parties
Position of the Complainant: The Employer is required to provide benefits for the seat lift because it is medically necessary.
Position of the Respondent: The Employer is not required to provide benefits for the seat lift because the medical information does not document that a seat lift is medically necessary in this case.
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.
Q&A #81-38 states in pertinent part:
Subject: Medical Equipment and Supplies
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (6) (d) and (e), and (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 (l.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
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 states that covered equipment includes, “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.” In RODs 84-135, 84-219 and 84-261 (copies enclosed herein) the Trustees have determined that a seat lift meets the criteria for durable medical equipment for which benefits may be provided under Article III A. (6)(d).
Although an item of DME may meet 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 this case, including letters from the Complainant’s physicians. The consultant has stated that these letters document the patient’s severe osteoarthritis of the hips and her difficulty in getting out of a chair to ambulate because of this condition. The consultant has advised that a seat lift is medically necessary for the treatment of the patient’s arthritis of both hips to prevent chair confinement and to retard deterioration of her condition, which would occur if she was unable to get out of her chair for frequent ambulation.
Inasmuch as the seat lift prescribed for the Complainant is a medically necessary item of durable medical equipment, it is a covered benefit under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for a seat lift, as was prescribed for the Complainant.