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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-269 – 1990年6月12日
Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
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 雇主 Benefit Plan.
背景事实
The 员工’s spouse had a heart attack in March 1988 and underwent cardiac rehabilitation. Her osteopathic physician prescribed an exercise treadmill in order for her to continue a regular exercise program and to maintain her cardiovascular fitness.
The 雇主 denied benefits for the exercise treadmill.
争端
Is the 雇主 required to provide benefits for the exercise treadmill prescribed for the 员工’s spouse?
Positions of the Parties
Position of the 员工: The 雇主 is required to provide benefits for the exercise treadmill because it is medically necessary for the 员工’s spouse to continue a regular exercise program and to maintain her cardiovascular fitness.
Position of the 雇主: The 雇主 is not required to provide benefits for the exercise treadmill 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)Cd) 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. (63(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 员工’s spouse’s osteopathic physician prescribed the exercise treadmill so that the 员工’s spouse could continue a regular exercise program and maintain her cardiovascular fitness. The exercise treadmill is a non-medical item that does not require professional judgment, recommendations or instructions to purchase or use. The Trustees have previously determined In ROD 88-148 (copy enclosed herein) that 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 treadmill is specifically excluded from coverage under the Plan.
Opinion of the Trustees
The 雇主 is not required to provide benefits for the exercise treadmill prescribed for the 员工’s spouse.