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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: 88-148 – 1989年8月2日
Board of Trustees: 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 exercise equipment under the terms of the 雇主 Benefit Plan.
背景事实
The 养老金领取者 had a total knee replacement of the right knee and has had open heart surgery. His physician prescribed an exercise bicycle for his home use to exercise his right knee, strengthen his lower extremities, and improve his cardiovascular condition.
The 雇主 denied benefits for the exercise bicycle.
争端
Is the 雇主 required to provide benefits for the exercise bicycle prescribed for the 养老金领取者?
Positions of the Parties
Position of the 养老金领取者: The 雇主 is required to provide benefits for the exercise bicycle because it is medically necessary for the 养老金领取者 to exercise his right knee and his cardiovascular system.
Position of the 雇主: The 雇主 is not required to provide benefits for the exercise bicycle because exercise equipment is specifically excluded under 第三条. A. (11) (a) 23. of the 雇主 Benefit Plan.
相关的规定
第三条. A. (6)(d) of the 雇主 Benefit Plan states:
(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.
第三条. A. (11) (a) 23. of the 雇主 Benefit Plan states in part:
(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
23. 运动器材
讨论
第三条. A. (6)(d) of the 雇主 Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.
在这种情况下, the physician prescribed the exercise bicycle so that the 养老金领取者 could exercise the right knee, strengthen his lower extremities, and improve his cardiovascular system. The exercise bicycle is a non-medical item that does not require professional judgment, 建议, or instructions to purchase or use. 根据Q&A 81-38 (copy enclosed herein) such items are considered convenience items and do not qualify as durable medical equipment under the 雇主 Benefit Plan. Furthermore, 第三条. A. (11) (a) 23. specifically excludes exercise equipment from coverage. Therefore, the exercise bicycle is specifically excluded from coverage under the Plan.
Opinion of the Trustees
The 雇主 is not required to provide benefits for the exercise bicycle prescribed for the 养老金领取者.