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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No.
In Re
Employee
Employer (Insurance Company) 25, October 17, 1979
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee
Pursuant to Article IX of the United Mine Workers of America 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 level of health benefits for obstetrical charges and hereby render their opinion on the matter.
Background Facts
Complainant is an active Employee eligible for the health benefits under Employer’s Plan. Employee’s dependent spouse was admitted to hospital for delivery on August 31, 1978. Anesthesia was administered to dependent spouse by attending physician during delivery.
Question or Dispute
The Employee filed a claim for coverage of the physician’s charges including charges for anesthesia services. The Insurance Company has denied payment for the anesthesia services. The Employer concurs with the Insurance Company’s decision.
Position of Parties
Claimant’s Position: The Employer (Insurance Company) is responsible for payment of the entire claim including the charges for anesthesia services.
Employer’s (Insurance Company) Position: The Employer (Insurance Company) is not responsible for that portion of payment of the claim covering anesthesia services since the anesthesia services are not covered when administered by attending physician under Article III, Section A(3)(d) of the Benefit Plan.
Applicable Regulations
Article III, Section A(3)(d) of the Employer Plan provides as follows:
Opinion of the Trustees ROD Case No. 25
Page 2
Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, who is not an employee of, nor compensated by, a hospital, laboratory or other institution.
Article III, Section A(10)(a)12 of the Employer Plan provides as follows:
In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following: Excessive charges as determined solely by the Plan Administrator.
Discussion
The governing provisions of the Plan exclude coverage for anesthesia services when administered by the attending physician.
Opinion of Trustees
The Trustees are of the opinion that the Employee is required to pay the anesthesia service charges incurred by the Employee’s dependent during the delivery procedure.