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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-546 – July 15, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, 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 exercise equipment under the terms of the Employer Benefit Plan.
Background Facts
In 1988, the Pensioner underwent a coronary artery bypass grafting and has, since that time, incurred the loss of both grafts. He was most recently studied in October of 1990 by means of a coronary angiography and both grafts were found to be occluded (closed). Additionally, disease was documented in the left anterior and posterior regions of his heart. The Pensioner’s cardiologist and family physician recommended an increase in the Pensioner’s exercise regimen in order to reduce weight and to improve overall exercise capacity and peripheral vascular tone. The cardiologist prescribed an exercise bicycle to help accomplish these goals since the Pensioner has significant arthritic complaints involving his knees, and a treadmill has not been well tolerated in the past.
The Employer denied benefits for the exercise bicycle.
Dispute
Is the Employer required to provide benefits for the exercise bicycle prescribed for the Pensioner?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the exercise bicycle because it is medically necessary for him to exercise regularly, and it is provided for under Article III. A. (6)(d) of the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide benefits for the exercise bicycle because exercise equipment is specifically excluded under Article III. A. (11)(a) 23. of the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (6)(d) of the Employer Benefit Plan states:
(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.
Article III. A. (11) (a) 23. of the Employer Benefit Plan states in pertinent part:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
23. Exercise equipment
Discussion
Article III. A. (6)(d) of the Employer Benefit Plan states that benefits are provided for medical equipment suitable for home use when determined to be medically necessary by a physician.
In this case, the Pensioner’s cardiologist prescribed the exercise bicycle so that the Pensioner could maintain a regular exercise program to improve his cardiac fitness. The Pensioner’s family physician also stated that the exercise bicycle is necessary to prevent further heart disease.
The Pensioner and his cardiologist further stated that an exercise regimen of walking or bicycling out of doors is not advisable because of the difficulty of the terrain and the lack of safety when walking or bicycling on country roads near the Pensioner’s home.
An exercise bicycle is a non-medical item that does not require professional judgment, physician recommendations, or instructions for purchase or use. The Trustees have previously determined in ROD 88-269 (copy enclosed herein) that such items are considered convenience items and do not qualify as durable medical equipment under the Employer Benefit Plan. Furthermore, Article III. A. (11) (a) 23. specifically excludes exercise equipment from coverage. Therefore, the exercise bicycle is specifically excluded from coverage under the Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the exercise bicycle prescribed for the Pensioner.