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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-530 – May 24, 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.
根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了这一争议的事实和情况，该争议涉及根据雇主福利计划的条款提供电动医院病床的福利.
Background Facts
雇员的配偶在她出院后租用了一张电动病床两个月, where she was treated for degenerative arthritis of the lumbar spine. 雇员说，他通过电话联系了雇主的保险公司，解释说需要这张床，以便他的妻子可以出院. 雇员表示，承运人通过电话授权他获得该床，并且他理解承运人将支付费用. The carrier subsequently denied payment of the charges for the bed.
雇主坚持认为，它从未事先批准雇员租用医院病床. 雇主表示，其承运人的惯例程序是，在一般意义上，对致电确认本计划项下的服务或物品是否可报销的受益人作出回应. 雇主声明，如果没有医疗需要的证明，承运人不同意提供福利. 雇主进一步指出，在这种情况下，电动病床的医疗必要性没有得到证实. 医生开具的病床处方(医疗证明表)直到病床安置在家一个月后才由医生签署，表格表明雇员的配偶在出院时可以走动.
Dispute
雇主是否负责为雇员的配偶租用电动医院病床提供健康福利?
Positions of the Parties
申诉人的立场:雇主负责支付医院电动病床的租金津贴，因为它使雇员的配偶得以出院, thus avoiding an extended period of hospitalization, 并事先获得雇主保险公司的租赁许可.
答辩人的立场:雇主不负责支付雇员配偶租用医院电动病床的费用，因为这在医学上不是必要的. 雇主未事先批准为雇员的配偶租用电动病床.
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, 购买医生认为必要的适合家庭使用的医疗设备.
Q&A 81-38 states:
Subject: Medical Equipment and Supplies
References:Amended 1950 & 1974 Benefit Plans & Trust, 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, 购买适合家庭使用的医疗设备和用品(包括有效使用设备所必需的物品)，但经医生确定为医疗需要. 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)在没有患病或受伤的情况下，一般来说对人是无用的, 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
Article III. A. 雇主福利计划(6)(d)规定，在医生确定有医疗需要时，为适合家庭使用的医疗设备提供福利.
Q&A 81-38 states that covered equipment includes, “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)在没有患病或受伤的情况下，一般来说对人是无用的, and (d) is appropriate for use in the home."为雇员配偶租用的电动病床符合所有四项标准. First, it can withstand repeated use. 第二，医院的电动病床主要和通常用于医疗目的.e., to enable bedridden patients to reposition themselves as necessary. Third, the bed would not be useful for persons who are not bedridden. Fourth, 电动病床可以在没有专业人员的帮助下安全操作，因此适合家庭使用.
Although an item of DME may meet the criteria outlined in Q&A 81-38, it is covered under Article III. A. (6) (d)只有在治疗疾病或受伤在医学上是必要的情况下，才适用雇主福利计划. 雇主声明，它提供的保险项目取决于是否满足该计划的医疗必要性条款，不保证保险或同意支付费用，除非有医疗必要性的证明. The Employer has a process for the submission of claims for DME, 包括由开处方的医生填写的医疗证明表格. The physician is required to explain the medical necessity of the item of DME. In this case, 直到将床安置在家中一个月后才签署医疗证明表格, 并指出雇员的配偶在出院时是可以走动的. Thus, the patient was not bedridden but merely required bed rest. 没有证据表明医生在出院时安排了一张病床，当然也不是作为出院的条件.
A皇冠搏彩中心网站的医疗顾问审查了本案的材料，认为医疗文件没有证明雇员配偶在医疗上需要使用电动病床两个月. 因为没有确定雇员配偶使用电动病床的医疗必要性, the Employer is not responsible for providing benefits for its rental.
Opinion of the Trustees
雇主不负责为雇员配偶租用医院电动病床提供健康福利.