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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 88-466 - 1991年12月17日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 the provision of benefits for a blood pressure monitor under the terms of the 雇主 Benefit Plan.
背景事实
The 养老金领取者 has been treated for high blood pressure for several years. His physician states that his blood pressure is labile (subject to change), and the 养老金领取者 therefore needs an automatic blood pressure monitor to check his blood pressure regularly at home.
争端
Is the 雇主 required to provide benefits for’ an automatic blood pressure monitor?
双方立场
Position of the 养老金领取者: The 雇主 is required to provide benefits for the automatic blood pressure monitor because the 养老金领取者’s physician has stated that the monitor is necessary to monitor his blood pressure at home.
Position of the 雇主: The 雇主 is not required to provide benefits for the automatic blood pressure machine because: (1) it can be purchased without a prescription or recommendation from a physician; (2) it is an item of convenience that is not necessary for the treatment of an illness or injury; and (3) anyone could benefit from its use.
相关的规定
第三条. A. (6)(d)雇主福利计划 states:
(6) 家庭健康服务 & 设备
(d) 医疗设备
提供租金或租金福利, 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, Sections 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. 包括DME项目的例子是手杖, commodes and other safety bathroom equipment, 家用透析设备, 医院的病床和床垫, 铁肺, 骨科框架和牵引装置, 氧气帐篷, 病人电梯, 呼吸机, 喷雾器, 助行器和轮椅.
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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, 吊袜腰带, 一次性纸杯或毛巾, 棉花球, 棉签, 急救绷带, 运动器材, 脚垫用于拇囊炎或老茧.
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讨论
根据第三条. A. (6)(d)雇主福利计划, benefits are provided for medical equipment suitable for home use when determined by a physician to be medically necessary. The type of medical equipment which is covered is further defined by Q&A 81-38, which states that covered medical equipment Is that which (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 blood pressure monitor meets all four criteria. 首先，它可以承受重复使用. 第二个, it is primarily and customarily used to serve a medical purpose, in this case to register and record blood pressure. Third, the monitor is not generally useful to a person in the absence of a blood pressure problem. 第四, the monitor can be safely operated without the assistance of professional personnel and is therefore suitable for home use.
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under 第三条. A. (6)(d)雇主福利计划 only if it is medically necessary for the treatment of an illness or injury. A Funds’ medical consultant has reviewed this file. The consultant notes that the prescription from the 养老金领取者’s physician provides no documentation of any unique needs of the patient. The consultant is of the opinion that the fact that the patient is under treatment for high blood pressure does not establish the medical necessity for such equipment, and therefore the purchase of this equipment is not medically necessary. 相应的, the 雇主 is not responsible for payment of benefits for the prescribed automatic blood pressure machine.
受托人的意见
The 雇主 is not required to provide benefits for the automatic blood pressure machine.