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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-516 – April 14, 1992
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 for durable medical equipment under the terms of the Employer Benefit Plan.
Background Facts
The spouse of a Pensioner fell in her home on September 6, 1990, injuring her back, lower lumbar region, pelvis and bruising her buttocks. Her doctor prescribed the use of a donut ring to ease the discomfort associated with sitting. The Employer denied the $8.30 charge as a non-covered expense, because the ring was a personal comfort item, and not for the treatment or diagnosis of an injury or illness.
Dispute
Is the Employer required to pay for the donut ring prescribed by the Pensioner’s spouse’s physician in relation to injuries she sustained on September 6, 1990?
Positions of the Parties
Position of the Pensioner: The Employer is required to pay for the donut ring, as it was medically necessary and prescribed by the doctor, in accordance with Article III. A. (6)(d).
Position of the Employer: The Employer is not required to pay for the donut ring, as it is a convenience item designed for comfort, and is not medically necessary.
Pertinent Provisions
Article III. A. (6)(d) of the Group Plan states in part:
(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
Article III. A. (6)(d) allows for the purchase of medical equipment deemed to be medically necessary by a physician. A Fund’s medical consultant has reviewed this file. He notes that the donut ring is useful for removing pressure from a sore point and distributing it to the surrounding area; it is also used in the treatment of fractured or bruised coccyx bones as well as for treatment of abscesses or sores in the perianal region. The consultant is of the opinion that the donut ring was properly prescribed and a medically justified medical equipment item. Therefore, the Trustees find that the Employer is responsible for the payment of the donut ring.
Opinion of the Trustees
The Employer is responsible for the payment of the medical equipment pursuant to Article III. A. (6)(d) of the Group Plan.