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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-069 - 1989年2月9日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
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 health benefits coverage for a heat pump and electronic air cleaners under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse has chronic allergies with hyperreactive airway dysfunction, including rhinitis and asthmatic bronchitis. In order to alleviate her symptoms, 各种补救措施, 包括药物治疗, surgery and relocation of her home, 已经尝试过了, 所有的成功都很有限. Two of her physicians stated that it would be to her advantage to change her home’s heating and cooling system to a heat pump to try to make her environment dust-free. The 员工 and his wife subsequently installed a heat pump and electronic air cleaners.
The 雇主 denied coverage for the purchase of the heat pump and air cleaners.
争端
Is the 雇主 responsible for the charges for the heat pump and electronic air cleaners?
双方立场
Position of the 员工: The 雇主 is responsible for the charges for the heat pump and electronic air cleaners because they are medically necessary for the treatment of the 员工’s spouse’s allergic condition.
Position of the 雇主: The 雇主 is not responsible for the charges for the heat pump and electronic air cleaners because the equipment is not primarily and customarily used to serve a medical purpose, 而是用来给住宅供暖的. 除了, the equipment is an environmental control device which would be beneficial to persons in the absence of an illness or injury.
相关的规定
第三条. A. (6)(d) of the 雇主 Benefit Plan provides:
(6) 家庭健康服务 & 设备
(d) 医疗设备
Benefits are provided for rental or, 在适当的地方, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&81-38州在相关部分:
主题: 医疗设备和用品
参考资料:1950年修订 & 1974年福利计划 & 信托皇冠搏彩中心网站
第三条, Section A (6) (d) and (e), and A (7) (a) and (d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
A. Under the 家庭健康服务 and 设备 provision, benefits are provided for the rental and, 在适当的地方 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 医疗设备 (DME) which (a) can withstand use (i.e., 通常可以租用), (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. Examples of covered DME items are canes, 洁具, and other safety bathroom equipment, 家用透析设备, 医院的病床和床垫, 铁肺, orthopedic frames and traction devices, 氧气帐篷, 病人电梯, 呼吸机, 喷雾器, 助行器和轮椅.
讨论
根据第三条. A. (6)(d) of the 雇主 Benefit Plan, benefits are provided for medical equipment. The type of medical equipment covered under 第三条 A. (6) (d)包括, 但不限于, durable medical equipment that (a) can withstand use; (b) is primarily and customarily used to serve 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.
The electronic air cleaners and heat pump are not covered durable equipment under the Plan because they are not primarily and customarily used to serve a medical purpose and because they may be useful to a person in the absence of an illness or injury. 除了, because the heat pump and air cleaner are general purpose environmental control devices, they are not otherwise covered medical equipment. 因此, the heat pump and electronic air cleaners do not meet the criteria for coverage under 第三条. A. (6)(d)计划. This decision is consistent with ROD Nos. 178, 304, 84-155, and 88-046 (copies enclosed herein), all of which held that air cleaners are not covered under 第三条 A. (6)(d).
受托人的意见
The heat pump and electronic air cleaners are not covered benefits under the 雇主 Benefit Plan.