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OPINION OF TRUSTEES

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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: CA-020 – July 16, 1998

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 health benefits coverage for a heart rate monitor under the terms of the Coal Industry Retiree Health Benefits Act of 1992 (Coal Act) Employer Benefit Plan, maintained pursuant to section 9711 of the Internal Revenue Code.

Background Facts

The Employee had a heart attack in 1989, following which it was recommended that he adopt an exercise program as part of his overall treatment. His physician states that, for the exercise to be of maximum benefit, the Employee’s heart rate should be maintained between 90 and 130 beats per minute. In December 1993, the Employee purchased a “Polar Heart Rate Monitor” at a local department store.

The Employer denied benefits, stating that the monitor was exercise equipment.

Dispute

Is the Employer required to provide benefits for the Employee’s heart rate monitor?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the heart rate monitor because it was medically necessary.

Position of the Employer: The Employer is not required to provide benefits for the heart rate monitor because it is exercise equipment.

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 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:

(11) General Exclusions

23. Exercise equipment.

Q&A 81-38 states, in pertinent part:

Question:

What medical equipment and supplies are covered under the Plan?

Answer:

A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following:

1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home.

C. Items of a convenience nature or those that do not require professional judgment, recommendations or instructions to purchase or use are not covered benefits. Examples of such items are: ordinary support (panty) hose, garter belts, disposable paper cups or towels, cotton balls, cotton swabs, bandaids, exercise equipment, and foot pads for bunions or calluses.

Discussion

The Introduction to Article III of the Employer Benefit Plan limits covered services to those which are reasonable and necessary to the diagnosis and treatment of an illness or injury. Article III A. (6) (d) provides benefits for medical equipment when determined to be medically necessary by a physician. Article III A. (11) (a) (23) excludes benefits for exercise equipment. Q&A 81-38 defines covered medical equipment.

The “Polar Heart Rate Monitor” prescribed by the Employee’s physician can be purchased in the sports/exercise departments of most large stores. Its purchase does not require a prescription, its use does not require professional judgment or instruction, and its widespread use by sports and exercise enthusiasts indicates that it is useful in the absence of an illness or injury. Therefore, this heart rate monitor cannot be considered medical equipment. This is also consistent with RODs 81-415, 88-148 and 88-269.

Since Article III A. (11) (a) (23) excludes benefits for exercise equipment, the Employer is not required to provide benefits for the heart rate monitor purchased by the Employee.

Opinion of the Trustees

Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the heart rate monitor purchased by the Employee.