_____________________________________________________________________________
受托人的意见
_____________________________________________________________________________
在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-103——1989年3月1日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
William Miller受托人; Donald E. 皮尔斯,小.受托人;
托马斯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 health benefits coverage for a liquid nutrient under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s four-year-old dependent daughter has multiple birth defects. 因为她身体无法吞咽, she is fed a liquid nutrient through a tube surgically inserted into her stomach. The 雇主 has denied payment for the liquid nutrient.
争端
Is the 雇主 required to provide benefits for the liquid nutrient used by the 员工’s daughter?
双方立场
Position of the 员工: The 雇主 is required to provide benefits for the liquid nutrient because it is’ necessary to sustain the child’s life.
Position of the 雇主: The 雇主 is not required to provide benefits for the liquid nutrient because it does not require a prescription for purchase.
相关的规定
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).
第三条. A. 雇主福利计划第(7)(a)条规定:
(7) 其他好处
(a) 矫形和假体设备
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when 医学上必要的.
包括以下类型的设备:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental. 包括人造眼睛, 鼻子, 手(或钩), 脚, 武器, 腿和造口袋和用品.
Q&81-38州在相关部分:
主题: 医疗设备和用品
参考资料:1950年修订 & 1974年福利计划 & 信托皇冠搏彩中心网站,
第三条, Sections A (6) (d) and (e), and A (7) (a) and (d)
问题:
What medical equipment and supplies are covered under the Plan?
答:
B. Under the 其他好处 provision, benefits are provided for the following:
1. Orthopedic and prosthetic devices prescribed by a physician when 医学上必要的, including items necessary for their effective use. These include, but are not limited to, the following items:
-prosthetic devices replacing internal or external body parts (other than dental), 比如心脏起搏器, maxillofacial devices and devices replacing all of the ear or nose, and waste collection and retention devices for incontinent people (e.g.、导尿管、造口袋及用品)
-prosthesis following breast removal, including surgical brassieres
-腿部，手臂，背部和颈部支架
桁架
-stump stocking and harnesses (see 第三条 Section A (7) (a) 5)
外科长袜(见1981年合同Q&A #46)
-orthopedic shoes and corrections (see 第三条 Section A (7) (a) 7 and 8)
2. Hearing aids (see 第三条 Section A (7) (d)).
讨论
The 员工’s daughter is unable to swallow and is being fed a nutritional formula, 完整的B, 通过胃造口管. 雇主认为, although the nutritional formula received by the 员工’s daughter was prescribed by a physician, a prescription is not required to purchase the formula. 引用第三条. A. (4)(a), 雇主认为, because 完整的B cannot be considered a prescription drug but is an over-the- counter medication or food supplement, 不在保险范围内. The 雇主 refers to numerous previous RODs in which the Trustees determined that benefits are generally not provided for infant formulas and diet supplements.
The distinguishing characteristic 在这种情况下, 然而, is that the child is receiving the nutritional formula 通过胃造口管, 一种假体装置. 第三条. A. (7) (a) 1. provides benefits for prosthetic devices prescribed by a physician when 医学上必要的. A prosthetic device is generally defined as a device that serves as a replacement fur an internal or external body part or function. Because the gastrostomy tube serves as a replacement for body parts that would normally permit food to reach the child’s lower digestive tract, 这个管子是一个假体装置. A Funds’ medical consultant has reviewed the file and stated that the gastrostomy tube is, 在这种情况下, 医学上必要的. Hence, the gastrostomy tube is a covered device. Indeed, the 雇主 does not contend otherwise.
此外,问&A 81-38 states that benefits are provided not only for prosthetic devices but for items necessary for their effective use. The 员工’s daughter’s physician prescribed the 完整的B formula. A Funds’ medical consultant has reviewed the file and has stated that the prescribed nutritional formula is 医学上必要的. 除了, 医疗保险 coverage guidelines provide that such nutrient solutions are routinely covered for patients who cannot be sustained through oral feeding. Because it is 医学上必要的 for the child to receive a special nutritional formula 通过胃造口管, the formula may be considered an item necessary for the medically effective use of the gastrostomy tube. Accordingly, benefits are provided for the nutritional formula 在这种情况下.
受托人的意见
The Respondent is required 在这种情况下 to provide benefits for the liquid nutrient used for the 员工’s daughter’s gastrostomy tube feedings.