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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-773 – February 6, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and
Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for paraffin baths under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse’s physician prescribed a paraffin wax unit to be used at home for treating the pain and stiffness in her hands. The spouse’s physician has not made a definitive diagnosis but has indicated that he suspects she may be suffering from early connective tissue disease or Raynaud’s Phenomenon, a syndrome that is manifested by attacks of pallor and cyanosis of the digits.
The Employer denied benefits for the paraffin bath unit under Article III.A.(11) 27. which states that any types of services, supplies or treatments not specifically provided for by the Plan are not covered.
Dispute
Is the Employer required to provide benefits for the paraffin bath unit prescribed for the Employee’s spouse?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s rental/purchase of the paraffin bath unit because it was prescribed by her physician as medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the rental/purchase of the Employee’s spouse’s paraffin bath unit because the Plan does not specifically state that benefits are available for this type of medical equipment.
Pertinent Provisions
Article III.A.(6)(d) 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) 27. states:
(11) General Exclusions
27. Any types of services, supplies or treatments not specifically provided by the Plan.
Discussion
Article III.A.(6)(d) of the Employer Benefit Plan provides for the rental or purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
The Employee’s spouse’s physician recommended paraffin wax baths to help treat the pain and stiffness in her hands. The physician noted that the Employee’s spouse’s possible diagnosis was early connective tissue disease or Raynaud’s Phenomenon, a syndrome that is manifested by attacks of pallor and cyanosis of the digits.
A Funds’ medical consultant has reviewed this file, including the medical records of the rheumatologist, and is of the opinion that the paraffin bath and mode of treatment do not provide a therapeutic benefit to the patient’s condition, but would provide some relief of symptoms when her hands become cold. The consultant further notes that there are other modes of warming hands, and there is no documentation that the use of the paraffin bath provides an improvement in the patient’s condition. Thus the paraffin bath unit would be more of a convenience item than one providing therapeutic treatment.
Additionally, Funds policy is to provide benefits for the rental or purchase of a paraffin bath unit when the patient has undergone a successful trial period of paraffin therapy ordered by a physician and the patient’s condition is expected to be relieved by long term use of this modality. The medical records supplied in this case do not document the successful completion of a trial period, nor any documentation of relief of the patient’s condition through use of this therapy.
Since there is no documentation of the completion of a successful trial period or that the use of the paraffin bath would provide a therapeutic benefit for the patient’s condition, the Trustees conclude that the Employer is not required to provide benefits for the Employee’s spouse’s rental/purchase of a paraffin bath unit.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s spouse’s rental/purchase of a paraffin bath unit.