____________________________________________________________________________
OPINION OF TRUSTEES
____________________________________________________________________________
In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 98-016 – November 13, 2002
Trustees: A. Frank Dunham, Michael H. Holland, Marty D. Hudson and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant’s spouse has muscle spasms in her lower back. To help alleviate her muscle spasms, her physician prescribed an RS-4 Neuromuscular Stimulator for use by the Complainant’s spouse at home. The Respondent has denied benefits coverage for the neuromuscular stimulator.
Dispute
Is the Respondent required to provide benefits coverage for the RS-4 Neuromuscular Stimulator prescribed for the Complainant’s spouse?
Position of the Parties
Position of the Complainant: The Respondent is required to provide coverage for the RS-4 Neuromuscular stimulator because the Complainant’s spouse’s physician prescribed the neuromuscular stimulator as part of the Complainant’s spouse’s home therapy.
Position of the Respondent: The Respondent is not required to provide coverage for the RS-4 Neuromuscular Stimulator because this type of equipment is not medically necessary, and it is not a covered benefit.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states, in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. . . .
Article III. A. (6) (d) of the 1998 Employer Benefit Plan provides:
Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be necessary by a physician.
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those that are medically necessary for the diagnosis and treatment of an illness or injury. A physician may prescribe services or treatment, but the medical necessity for such care must be established before benefits may be provided under the Plan. Under Article III. A. (6) (d) of the Employer Benefit Plan, benefits are provided for medical equipment.
A Funds’ medical consultant has reviewed the documentation submitted and has concluded that there is inadequate medical justification to approve the neuromusclar stimulator on the basis of medical necessity.
Opinion of the Trustees
The Respondent is not required to provide coverage for the RS-4 Neuromuscular Stimulator prescribed for the Complainant’s spouse.