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OPINION OF TRUSTEES
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In-Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-636 – June 28, 1988

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee

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 pillow casings and mattress covers for an Employee’s dependent son under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s dependent son has perennial and seasonal allergic rhinitis (inflammation of the mucous membrane of the nose) and headaches. His physician prescribed zippered airtight covers for his mattress, box springs and pillows because of his severe dust allergy.

The Employer denied benefits for the pillow and mattress encasings stating that they are personal comfort items which are not medically necessary for the treatment of an illness and are excluded from coverage under the Employer Benefit Plan.

Dispute

Is the Employer responsible for providing benefits for the pillow and mattress encasings prescribed for the Employee’s son?

Positions of the Parties

Position of the Employee: The Employer is responsible for providing benefits for the pillow and mattress encasings.

Position of the Employer: The Employer is not responsible for providing benefits for the pillow and mattress encasings because they are personal comfort items which are not medically necessary for the treatment of the Employee’s son’s allergies.

Pertinent Provisions

Article III. A. (6)(d) of the 1984 Employer Benefit Plan states:

(d) Medical Equipment

Benefits are provided for rental or, where appropriate, purchase of medical equipment suitable for home use when determined to be medically necessary by a physician.

Article III. A. (11) (a) 9. of the 1984 Employer Benefit Plan states:

(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.

Q & A 81-38 states in pertinent part:

Subject: Medical Equipment and Supplies

References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (d) and (e), and A (7) (a) and (d)

Question:

What medical equipment and supplies are covered under the Plan?

Answer:

A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate 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:

2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called “Chux” or “blue pads”), supplies for home management of open or draining wounds, heating pads (for therapeutic use only) and insulin needles and syringes.

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, garter belts, disposable paper cups or towels, cotton balls, cotton swabs, bandaids, exercise equipment, and foot pads for bunions or calluses.

Discussion

Article III. A. (6)(d) of the Employer Benefit Plan provides benefits for medical equipment suitable for home use when determined to be medically necessary by a physician.

In this case, the physician prescribed airtight covers for the Employee’s son’s mattress, box springs and pillows in order to limit the boy’s exposure to dust particles to which he is allergic. The pillows and mattress encasings are non-medical, environmental control supplies which do not require professional judgment, recommendations or instructions to purchase or use. According to Q&A 81-38, such items are considered convenience items and do not qualify as durable medical equipment under the Employer Benefit Plan.

Opinion of the Trustees

The Employer is not responsible for providing benefits for the pillow, mattress and box springs covers prescribed for the Employee’s son.