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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 07-0012 – October 24, 2007
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant’s spouse is afflicted with the autoimmune disease of Alopecia. Her primary care physician and a psychiatric professional have prescribed a cranial prosthesis (wig) as medically necessary for the treatment of her condition and its associated afflictions. The Plan Administrator has denied the prescription as not medically necessary.
Dispute
Is the Employer required to provide benefits for the purchase of the Complainant’s spouse’s cranial prosthesis?
Positions of the Parties
Position of the Complainant: The cranial prosthesis has been prescribed by the primary care physician and consulting psychiatric professional as medically necessary to the recovery from a medical condition. Respondent should provide benefits for the purchase of the cranial prosthesis.
Position of the Respondent: The Employer is not required to provide benefits for the Complainant’s spouse’s cranial prosthesis because wigs are not listed among the covered prosthetic devices under Article III. A. (7) (a) of the Employer Benefit Plan. The cranial prosthesis requested by the Complainant is a personal comfort item not necessary to the treatment of an illness or injury. The Employer states that its position is further supported by previous decisions of the Trustees in Q & A 81-73, ROD 88-321 and ROD 88-154.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in pertinent part:
Article III — Benefits
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….
Article III. A. (7) (a) of the Employer Benefit Plan states, in pertinent part:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices
prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external
body parts, other than dental.
These include artificial eyes, noses, hands (or hooks), feet, arm, legs and ostomy bags and supplies.
2. Prothesis following breast removal.
3. Leg, arm, back, and neck braces.
4. Trusses
5. Stump stockings and harnesses when these devices are essential
for the effective use of an artificial limb. An examination and
recommendations by an orthopedic physician are required.
* * *
6. Surgical stockings (up to two pairs per prescription with no refills)
when prescribed by a physician for surgical or medical conditions.
The Plan will not pay Beneficiaries for support hose, garter belts, etc.
7. Orthopedic shoes when specifically prescribed by a physician or
licensed podiatrist for a Beneficiary according to orthopedist
specifications, including orthopedic shoes attached to a brace that
have to be modified to accommodate the brace. Benefits will not be
provided for stock orthopedic shoes.
8. Orthopedic corrections added to ordinary shoes by a physician or
licensed podiatrist. Benefits are provided for only the correction to the
shoe.
Article III. A. (11)(a) 9. and 27. of the Employer Benefit Plan state:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits
are also not provided for the following:
* * *
9. Personal services such as barber services, guest meals and cots,
telephone or rental of radio or television and personal comfort items
not necessary to the treatment of an illness or injury.
* * *
27. Any types of services, supplies or treatments not specifically
provided by the Plan.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services that are reasonable and necessary for the diagnosis or treatment of
an illness or injury and that are given at the appropriate level of care, or are otherwise provided for in the Plan. Article III. A. (7) (a) of the Employer Benefit Plan provides health benefits coverage for orthopedic and prosthetic devices prescribed by a physician when medically necessary. Article III. A. (11)(a) 9 states that benefits are not provided for personal services and personal comfort items not necessary for the treatment of an illness or injury. Article III. A. (11)(a) 27 states that benefits are not provided for any types of services, supplies or treatments not specifically provided for by the Plan.
The Complainant’s spouse experienced hair loss as a result of a medical condition. The Respondent has refused to provide benefits for the purchase of a total scalp prosthesis (wig) prescribed by the primary care physician. The wig is a replacement for the hair the Complainant’s spouse lost due to her condition. However, a wig is not one of the prosthetic devices in Article III. A. (7) (a) of the Employer Benefit Plan, for which benefits may be provided. In ROD 88-154 (copy enclosed herein), the Trustees determined that benefits are not provided for wigs that compensate for hair loss caused by disease or chemotherapy treatment because these wigs are considered cosmetic or personal comfort items not necessary to the treatment of an illness or injury. Funds’ Medical Director reviewed the submitted documentation and determined that while the cranial prosthesis would provide psychological comfort to the Complainant’s spouse, it is not necessary for the treatment of her illness of cranial alopecia.
Opinion of the Trustees
The Employer is not required to provide benefits for the purchase of a wig for the Complainant’s spouse.