_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-455 – October 29, 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 insulin injection device under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s 19-year-old son has juvenile onset diabetes mellitus, a chronic form of diabetes involving insulin deficiency, and he receives insulin injections twice daily. His physician has stated that he has good diabetic control, but he frequently has a small amount of bleeding at the injection site and has numerous bruises. The physician has prescribed a Medi-Jector needle-free insulin injection device, stating that he thinks its use will decrease the Employee’s son’s hemorrhagic response to insulin Injections and will relieve a disturbing side effect from injections with a needle. The Employer has denied benefits for the purchase of -the insulin Injection device.
Dispute
Is the Employer required to provide benefits for the insulin injection device?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the needle-free insulin injection device because injections with a needle have resulted in bleeding and other problems.
Position of the Employer: The Employer is not required to provide benefits for the insulin injection device because it is an item of convenience and is not medically necessary for the treatment of the Employee’s son’s diabetes; regular insulin syringes would serve the same purpose at a more reasonable cost.
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.
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 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:
…
2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue pads”), supplies for home management of open or draining wounds, heating pads (for therapeutic use only] and insulin needles and syringes.
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, under the Home Health Services and Equipment provision, benefits are provided for certain types of medical equipment and supplies, including insulin needles and syringes.
A Funds’ medical consultant has reviewed this file, including a letter from the Employee’s son’s physician. He notes that the prescribed Medi-Jector is an alternative means of delivering the patient’s insulin by using a jet of air instead of a needle. The consultant finds no medical documentation to indicate that the patient’s bleeding cannot be controlled by better technique using traditional means of insulin injection. The consultant further states that there is no medical evidence that the patient has a bleeding disorder and no medical evidence that the Medi-Jector produces less bleeding or a smaller contusion. The consultant is of the opinion that the use of a Medi-Jector in this case would not provide any medical advantages over a conventional hypodermic insulin syringe and is not medically necessary.
Since the insulin injection device prescribed in this case is not medically necessary, the Employer is not required to provide benefits for it under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the insulin injection device.