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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-321 – October 12, 1990
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee;
William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas K. Saggau,
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 the purchase of a wig under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s daughter suffers from trichotillomania, a medical condition that has resulted in a complete loss of all her scalp hair. The Employer has refused to provide benefits for the purchase of a wig.
Dispute
Is the Employer required to provide benefits for the purchase of the Employee’s daughter’s wig?
Positions of the Parties
Position of the Complainant: The Employee asks whether the Employer is required to pay for the Employee’s daughter’s wig prescribed by her physician as a total scalp hair prosthesis that would enable her to engage in activities outside the home.
Position of the Respondent: The Employer is not required to provide benefits for the Employee’s daughter’s wig because a wig is not listed among the covered prosthetic devices under Article III. A. (7) (a) of the Employer Benefit Plan and because benefits are not provided for personal comfort items not necessary to the treatment of an illness or injury. The Employer states that its position is further supported by a previous decision of the Trustees in 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 is 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 Plan provides health benefits coverage for orthopedic and prosthetic devices prescribed by a physician when medically necessary. Article III. A. (11)(a) 9. of the Plan states that benefits are not provided for personal services and personal comfort items not necessary to the treatment of an illness or injury. In addition, 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.
In this case, the Employee’s daughter experienced hair loss as a result of a medical condition. The Employer has refused to provide benefits for the purchase of a wig prescribed by the Employee’s daughter’s physician as a total scalp prosthesis. The Employee’s daughter’s wig serves as a replacement for the hair she has lost because of her condition. However, a wig is not one of the prosthetic devices listed under Article III. A. (7) (a) of the Plan for which benefits may be provided. In ROD 88-154 (copy enclosed herein), the Trustees determined
that benefits are not provided for wigs necessary because of hair loss caused by disease or chemotherapy treatment as such wigs are considered cosmetic or personal comfort items not necessary to the treatment of an illness or injury. Because benefits are not specifically provided by the plan for the purchase of wigs and because a wig is a cosmetic item not necessary to the treatment of the Employee’s daughter’s condition, the Employer is not required to provide benefits for the purchase of the Employee’s daughter’s wig.
Opinion of the Trustees
The Employer is not required to provide benefits for the purchase of the Employee’s daughter’s wig.