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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-069 – February 9, 1989
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 health benefits coverage for a heat pump and electronic air cleaners under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has chronic allergies with hyperreactive airway dysfunction, including rhinitis and asthmatic bronchitis. In order to alleviate her symptoms, various remedies, including medications, surgery and relocation of her home, have been tried, all with limited success. Two of her physicians stated that it would be to her advantage to change her home’s heating and cooling system to a heat pump to try to make her environment dust-free. The Employee and his wife subsequently installed a heat pump and electronic air cleaners.
The Employer denied coverage for the purchase of the heat pump and air cleaners.
Dispute
Is the Employer responsible for the charges for the heat pump and electronic air cleaners?
Positions of the Parties
Position of the Employee: The Employer is responsible for the charges for the heat pump and electronic air cleaners because they are medically necessary for the treatment of the Employee’s spouse’s allergic condition.
Position of the Employer: The Employer is not responsible for the charges for the heat pump and electronic air cleaners because the equipment is not primarily and customarily used to serve a medical purpose, but is used to heat a residence. In addition, the equipment is an environmental control device which would be beneficial to persons in the absence of an illness or injury.
Pertinent Provisions
Article III. A. (6)(d) of the Employer Benefit Plan provides:
(6) Home Health Services & Equipment
(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.
Q&A 81-38 states in pertinent part:
Subject: Medical Equipment and Supplies
References: Amended 1950 & 1974 Benefit Plans & Trusts
Article III, Section 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:
1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (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. Examples of covered DME items are canes, commodes, and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs.
Discussion
Under Article III. A. (6)(d) of the Employer Benefit Plan, benefits are provided for medical equipment. The type of medical equipment covered under Article III A. (6)(d) includes, but is not limited to, durable medical equipment that (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 electronic air cleaners and heat pump are not covered durable equipment under the Plan because they are not primarily and customarily used to serve a medical purpose and because they may be useful to a person in the absence of an illness or injury. In addition, because the heat pump and air cleaner are general purpose environmental control devices, they are not otherwise covered medical equipment. Therefore, the heat pump and electronic air cleaners do not meet the criteria for coverage under Article III. A. (6)(d) of the Plan. This decision is consistent with ROD Nos. 178, 304, 84-155, and 88-046 (copies enclosed herein), all of which held that air cleaners are not covered under Article III A. (6)(d).
Opinion of Trustees
The heat pump and electronic air cleaners are not covered benefits under the Employer Benefit Plan.