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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-476 – December 11, 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 visual therapy under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s 15-year old daughter has been diagnosed with convergence insufficiency, a problem in which her eyes fail to point properly at near tasks. She was treated by an optometrist with two orthoptic/pleoptic therapy sessions, which involved eye exercises to strengthen the eye muscles and assure proper binocular cooperation of the eyes.

The Employer has denied benefits for the two visual therapy sessions.

Dispute

Is the Employer required to provide benefits for the orthoptic/pleoptic therapy sessions for the Employee’s daughter?

Positions of the Parties

Position of the Employee: The Employee asks whether the services are covered under the Employer Benefit Plan.

Position of the Employer: The Employer is not required to provide benefits for orthoptic/pleoptic therapy because such therapy is not covered under the medical provisions of the Employer Benefit Plan, and is specifically excluded under the vision care provisions of the Employer Benefit Plan.

Pertinent Provisions

Article III. A. (9)(c) 4. of the Employer Benefit Plan states:

(9) Vision Care Program

(c) Exclusions include:

4. Special procedures, such as orthoptics, vision training, subnormal vision aids, aniseikonic lenses and tonography;

Article III. A. (11) (a) 27 of the Employer Benefit Plan states:

(11) General Exclusions

(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

27. Any types of services, supplies or treatments not specifically provided by the Plan.

Discussion

Article III. A. (9)(c) 4. of the Employer Benefit Plan states that special procedures such as orthoptics and vision training are specifically excluded from coverage under the vision care program of the Plan. Article III. A. (11) (a) 27. of the Employer Benefit Plan states that any service not specifically provided by the terms of the Plan is excluded from coverage.

Inasmuch as orthoptics and vision training are specifically excluded from coverage under the vision care program and the medical portion of the Plan contains no provision for visual therapy, the visual therapy services provided to the Employee’s daughter are not covered under the Employer Benefit Plan.

Opinion of the Trustees

The Employer is not required to provide benefits for the orthoptic/pleoptic therapy sessions for the Employee’s daughter.