OPINION OF TRUSTEES
ROD Case No: 93-040 – September 11, 1996
Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for ambulette services under the terms of the Employer Benefit Plan.
The Employee’s spouse has end stage renal disease (ESRD) due to diabetes mellitus and requires renal dialysis three times a week to sustain her life. Other medical complications include gastrointestinal bleeding, hypertension, impaired vision, anemia and malnutrition. Her physical condition precludes her driving herself to the dialysis center and there are no other family members or friends available to drive her. Therefore, she relies on an ambulette for her transportation. The charge for this service is $60.00 per round trip.
The Employer is providing benefits in the amount of 20¢ per mile and cites ROD 88-241 in support of its position.
Is the Employer required to provide benefits for the Employee’s spouse’s transport by ambulette?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the ambulette because it is necessary to transport the Employee’s spouse to the dialysis center.
Position of the Employer: The Employer is not required to provide benefits for the ambulette because it is not the least expensive transportation available; ROD 88-241 supports this position.
Article III A. (7). (e) states:
(7) Other Benefits
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a hospital, clinic, medical center, physician’s office, or skilled nursing care facility, when considered medically necessary by a physician.
With prior approval from the Plan Administrator benefits will also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out-of-area medical center.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or clinic for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
Article III A. (7) (e) of the Employer Benefit Plan provides benefits for transportation other than ambulance, with prior approval of the Plan Administrator, when a Beneficiary requires frequent transportation for treatment that would otherwise require hospitalization, and the care cannot be obtained without such transportation. In this instance, the Employee’s spouse requires renal dialysis three times each week to sustain her life and must be transported to the dialysis center to receive these treatments. A physician at the dialysis center has submitted a letter in support of the Employee’s spouse’s need for ambulette (minivan) transportation. The Plan Administrator has agreed only to provide reimbursement for mileage incurred by private car.
The Employer has cited ROD 88-241 (copy enclosed herein) in support of its position. The issue in that case was whether the Employer was required to provide benefits for the charges of the escort and meal expenses since the Employer had provided a mileage allowance for the use of a car. In that case, a car provided by a friend was the least expensive feasible method of transportation and the Employer provided benefits on that basis.
Since there is no family member or friend available to drive the Employee’s spouse to her dialysis treatments, transportation by private car is not an feasible option. In such a circumstance, it is Funds policy and practice to provide benefits for ambulette. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for ambulette transportation of the Employee’s spouse between the home and the dialysis center.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the ambulette transportation of the Employee’s spouse between home and the dialysis center.