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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: 84-135——1986年9月30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 Nine 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 health benefits coverage for the rental of a seat lift chair under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse was being treated for osteoarthritis of both knees and cancer of the lung which had spread to the brain. As part of the treatment program the physician prescribed a seat lift chair (more commonly referred to as a “seat lift”) to prevent bed or wheelchair confinement, minimize the patient’s disability and allow her to function to the maximum of her capacity.
座位升降是在2月6日规定的, 1985 and supplied on a monthly rental basis until the patient’s death on July 19, 1985. The 雇主 paid the charges for the first month’s rental but denied charges for the subsequent five months. No explanation was offered as to the reason the first month’s rental was paid.
争端
Is the 雇主 responsible for paying benefits for the rental of a seat lift?
双方立场
Position of the 员工: The 雇主 is responsible for paying benefits for the seat lift, because it was medically necessary and appropriate for treatment of the 员工’s spouse’s condition.
Position of the 雇主: The 雇主 is not responsible for paying benefits for the seat lift because seat lifts are convenience items and are not therapeutically effective in the treatment of osteoarthritis of the knees.
相关的规定
第三条 A (8) (d) of the 雇主 Benefit Plan states:
(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:
主题: 医疗设备和用品
引用:修改1950 & 1974年福利计划 & 信托皇冠搏彩中心网站,
第三条, Section A (5) (d) and (e), and A (7) (a) and (d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
A. 根据家庭保健服务和设备条款, 提供租金和福利, 在计划管理人决定的适当情况下, 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, (d)适合在家中使用. 包括DME项目的例子是手杖, 盥洗用具及其他安全卫浴设备, 家用透析设备, 医院的病床和床垫, 铁肺, 矫形框架和
traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. 有盖补给的例子是灌肠补给, disposable sheets and pads (also called “Chux” or “blue pads”), 家庭管理开放性或渗水伤口的用品, heating pads (for therapeutic use only) and insulin needles and syringes.
3. 第III条第A (6) (e)节规定的氧气.
讨论
第三条. A. (6)(d) of the 雇主 Benefit Plan provides coverage for the rental of medical equipment suitable for home use when determined to be medically necessary by a physician.
Q&81-38州涵盖的设备包括, “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, (d)适合在家中使用.” The seat lift chair rented for the 员工’s spouse meets all four criteria. 首先，它可以承受重复使用. 第二个, a seat lift is primarily and customarily used for a medical purpose, 这是, 协助行动不便人士坐立. 第三, the lift function of the chair would not be necessary for persons who do not have an illness or injury that causes an impairment of mobility. 第四, the seat lift 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，这是第三条规定的. A. (8)(d) of the 雇主 Benefit Plan only if a physician determines that it is medically necessary for the treatment of an illness or injury. Three of the 员工’s spouse’s physicians have stated that she had arthritis of both knees. The condition was of such severity that it was treated with both oral medication and injections into the knee joints. The prescribing physician stated on the Certificate of Medical Necessity that the seat lift was medically necessary and that it was needed to prevent bed or wheelchair confinement. 此外, the orthopedic physician stated in his letter of October 30, 1985 that the seat lift chair was necessary to alleviate pain. 因此, the seat lift was medically necessary for the treatment of the 员工’s spouse’s arthritis.
The seat lift that was rented for the 员工’s spouse was an item of durable medical equipment suitable for home use and was determined by a physician to be medically necessary; therefore, 它是雇主福利计划下的一项涵盖福利.
受托人的意见
The 雇主 is responsible for providing benefits for the seat lift used by the 员工’s spouse from February 8, 1985年至7月19日, 1985.