Opinion of the Trustees ROD Case No. 61
Page 1
November 8, 1979
(Opinion issued in letter form; name and address deleted)
Re: Resolution of Dispute Case No. 61
This is in response to your request for an opinion from the Trustees of the UMWA Health and Retirement Funds concerning copayments for physicians visits during hospitalization.
The Employer’s benefit plan provides in Article III, A (3)(g) that if a beneficiary is confined as an inpatient because of an illness or injury, benefits are provided for in-hospital visits by the physician in charge of the case. According to Article III, A (8)(a) of the Employer’s benefit plan, in-hospital physician visits are subject to a $7.50 copayment per visit, up to a maximum of $150 per calendar year per family. 1978 Contract Q&A #68 further states:
Question: Are pre- and post-surgery visits subject to copayment?
Answer: A pre- or post-surgery physician visit billed separately from the surgical procedure, whether it takes place on an inpatient or outpatient basis, is subject to copayment.
The surgical procedure consisting of operative and cutting procedures and including the usual and necessary post-operative care, is not subject to copayment.
Therefore if a beneficiary is confined as an inpatient because of surgery or illness, each in- hospital physician visit is subject to copayment. The surgical procedure, including the usual and necessary post-operative care, is not subject to copayment.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
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Paul R. Dean, Trustee