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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-129 – February 24, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee;, William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
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 for eyeglasses under the terms of the Employer Benefit Plan.
Background Facts
The Employee had surgery on his right eye for cataract removal and intraocular lens (IOL) implant. Three months later, similar surgery was performed on his left eye. After each surgery, the attending ophthalmologist prescribed a new eyeglass lens for the affected eye in order to restore visual acuity to the same level of acuity (20/20, with correction, in each eye) the Employee had prior to surgery. The eyeglasses the Employee wore before his cataract surgery did not provide the additional correction needed as a result of the loss of acuity caused by the surgery. In addition, they did not have the ultraviolet absorbing lenses which are needed to protect the eyes following cataract surgery.
Question or Dispute
Is the Employer responsible for paying benefits for the eyeglasses the Employee received following cataract surgery and IOL implants?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of the benefits for the eyeglasses the Employee required to correct his vision following cataract surgery and IOL implants.
Position of the Employer: The Employer is not responsible for payment of benefits for both eyeglasses and IOL implants because the IOL implants by themselves are corrective lenses, and payment for them satisfies the Employer’s responsibility for the provision of benefits for eyeglasses or lenses required because of a surgically caused refractive error. In this case, the eyeglasses could only be covered under the vision care program. However, the Employer paid benefits for eyeglasses under the vision care program less than two years before the beneficiary received the eyeglasses following the cataract surgery and IOL implants, so that vision care benefits were not payable under the frequency limits of the vision care program.
Pertinent Provisions
Article III. Section A. (11) (a) 22. of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
22. Eyeglasses or lenses, except when medically required because of surgically caused refractive errors or as otherwise provided in section A(9).
Discussion
Under Article Ill. Section A (11) (a) 22. of the Employer Benefit Plan, benefits are provided for eyeglasses or lenses when medically required because of a surgically caused refractive error. Cataract surgery causes a refractive error because it involves removal of the lens. The marked decrease in visual acuity associated with removal of the natural lens requires the use of a prosthetic lens or a combination of prosthetic lenses to restore vision. The types of prosthetic lenses which are available include IOLs, contact lenses, and eyeglass lenses.
In this case, the Employee wore eyeglasses for myopia before surgery. After surgery–and, therefore, with IOL implants–the Employee had hyperopia and astigmatism in one eye and myopia and astigmatism in the other eye. The degree of refractive error which existed after the surgery was markedly different from the degree of refractive error which existed prior to the surgery, and new eyeglasses were needed in conjunction with the IOLs for the Employee to have normal visual acuity. Correction of the refractive error caused by the surgical removal of the Employee’s natural lenses required both IOLs and prosthetic-lens eyeglasses. In addition, ultraviolet absorbing lenses were prescribed for the eyeglasses to protect the Employee’s eyes from potentially harmful rays from the sun.
Because a combination of IOLs and eyeglasses is medically required to correct the Complainant’s surgically caused refractive error, both types of lenses are covered under Article III A (11) (a) 22.
Opinion of the Trustees
The Employer is responsible for payment of the charges for the combination of lenses, that is, intraocular implants and eyeglasses, which the Employee required as the result of surgically caused refractive error.