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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: 84-502 – 1987年12月10日

Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,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 prescription drugs under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse lost sixty pounds in one year and was found to be nutritionally deficient. Her physician prescribed the nutritional formula, Ensure, to be taken as a diet supplement. Ensure does not require a prescription and is obtained over the counter. The 雇主 denied coverage for the nutritional supplement.

争端

Is the 雇主 responsible for the provision of prescription drug benefits for the 员工’s spouse’s diet supplement?

Positions of the Parties

Position of the 员工: The 雇主 is responsible for the provision of prescription drug benefits for the 员工’s spouse’s diet supplement because it was prescribed by a physician.

Position of the 雇主: The 雇主 is not responsible for providing prescription drug benefits for the 员工’s spouse’s diet supplement. Although it was prescribed by a physician, it does not require a prescription in order to be purchased.

Pertinent Provisions

第三条. A. (4)(a) of the 雇主 Benefit Plan states in part:

(4) 处方药

(a) 提供的福利

Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or a nonoccupational accident…

讨论

根据第三条. A. (4)(a) of the 雇主 Benefit Plan benefits are provided only for those drugs which, by federal or state law, require a prescription. Medication that can be obtained over the counter without a prescription is excluded from coverage. The Trustees have previously concluded in Resolutions of 争端 81-561 and 84-098 (copies enclosed herein) that benefits are not provided under the 雇主 Benefit Plan for nutritional supplements which do not require a prescription. 在这种情况下, although the Ensure needed by the 员工’s spouse was prescribed by a physician, it did not require a prescription for purchase. Therefore, benefits are not provided for this supplement under the 雇主 Benefit Plan.

Opinion of the Trustees

The 雇主 is not responsible for the provision of benefits for the diet supplement Ensure.