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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-007 – July 12, 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.
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 speech therapy under the terms of the Employer Benefit Plan.
Background Facts
The Employee is 35 years old and has stuttered since early childhood. After the Employee’s physician provided a referral for speech therapy for his stuttering, the Employee was evaluated by a speech therapist on January 18, 1988. The speech therapist recommended that he receive speech therapy 2-3 times per week. The Employee maintains that speech therapy should be a covered benefit in his case because his impairment prevents him from advancing on his job. He states his stuttering could prevent him from speaking quickly and clearly during emergencies.
The Employer denied coverage for the Employee’s speech therapy because the Employee’s condition does not meet the requirements for coverage of speech therapy stipulated in the Employer Benefit Plan.
Dispute
Is the Employer responsible for providing coverage for the Employee’s speech therapy?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing coverage for the Employee’s speech therapy because his stuttering prevents him from leading a normal life, advancing on his job, and speaking quickly and clearly during emergencies.
Position of the Employer: The Employer is not responsible for providing coverage for the Employee’s speech therapy because the Employee’s condition does not meet the requirements for coverage of speech therapy stipulated in Article III. A. (7)(c) of the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (7)(c) of the Employer Benefit Plan states:
(7) Other Benefits
(c) Speech Therapy
Benefits are provided for speech therapy rendered by a qualified licensed speech therapist if the Beneficiary is a stroke patient or has had conditions including ruptured aneurysm, brain tumors or autism and needs special instruction to restore technique of sound and to phonate, and needs direction in letter and word exercises in order to express basic needs. Benefits are also provided for speech therapy for child Beneficiaries with a speech impediment from a qualified speech therapist provided that the child cannot receive speech therapy through the public schools.
Discussion
Under Article III. A. (7)(c) of the Employer Benefit Plan, benefits are provided for speech therapy rendered by a qualified, licensed, speech therapist if the Beneficiary is a stroke patient or has had conditions including a ruptured aneurysm, brain tumors or autism and needs special instruction to restore technique of sound and to phonate and needs direction in letter and word exercises in order to express basic needs. Benefits are also provided for speech therapy for child Beneficiaries with a speech impediment.
Because the Employee in this case does not have a medical condition which has impaired his ability to express basic needs as described in Article III. A. (7)(c) of the Plan, and because under that provision, coverage for speech therapy for a beneficiary with a speech impediment is limited to children, the Employee’s speech therapy is not a covered benefit.
Opinion of the Trustees
The Employer is not responsible for providing coverage for the Employee’s speech therapy.