Opinion of Trustees
Resolution of Dispute
Case No. 81-307
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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
81-307 – August 29, 1983
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 payment of private room charges under the Employer’s Plan and hereby render their opinion in the matter.
Background Facts
The Employee was hospitalized at the Holston Valley Hospital and Medical Center from January 28, 1983 through February 18, 1983, and at St. Mary’s Hospital from March 19, 1983 through April 2, 1983. During both admissions, the Employee was confined in a private room. The Employee contends that his physicians had recommended that he be placed in a private room, and therefore the Employer should pay the private room rate. Regarding the Employee’s hospitalization at Holston Valley Hospital, Dr. J. Michael Bookout stated that “I felt it was necessary that he have a private room during this hospitalization to improve progress.” Addressing the Employee’s private room confinement at St. Mary’s Hospital, Dr. G.S. Kanwal stated that “I believe his being treated in a private room helped his improvement of his nerves.” The Employer provided coverage in an amount equal to the hospitals’ most common charges for semi-private room accommodations, but denied payment for the private room charges.
Question or Dispute
Is the Employer responsible for coverage of charges for private room rates in excess of the charges for semi-private room accommodations during the Employee’s two hospital stays.
Position of the Parties
Claimant’s Position: The Employer is responsible for the private room charges since the Employee’s doctors recommended a private room due to the condition of his nerves.
Opinion of Trustees Resolution of Dispute Case No. 81-307
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Employer’s Position: According to Article III A (1) (c) of the Employer’s Benefit Plan, benefits for private room charges are only allowed under special circumstances. Because neither Dr. Bookout nor Dr. Kanwal certified that the Employee’s confinement in a private room was required to isolate him for his own health or the health of others, and because there is no evidence that semi-private room accommodations were not available, the Employer determined that the Employee’s confinement in a private room was not medically necessary and did not satisfy the provisions of the plan. Payment of charges for a private room should therefore be denied.
Pertinent Provisions
Article III, Section A (1) (c) of the Employer’s Plan provides as follows:
For confinement in a private room, benefits will be provided for the hospital’s most common charge for semi-private room accommodations and the Beneficiary shall be responsible for any excess over such charge except that private room rates will be paid when (i) the Beneficiary’s condition requires him to be isolated for his own health or that of others, or (ii) the hospital has semi-private or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. Semi- private room rates, not private room rates, will be paid beyond the date a semi-private room first becomes available and the Beneficiary’s condition permits transfer to those accommodations.
Article III, Section A (11) (a) (10) of the Employer’s Benefit Plan provides under General Exclusions as follows:
In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
(10) Charges for private room confinement, except as specifically described in the Plan.
Discussion
Pursuant to Article III A 1 (c) of the Employer’s Benefit Plan, an Employer is responsible for the payment of private room rates when an Employee’s condition requires him to be isolated for his own health or that of others, or if the Employee requires immediate hospitalization and only a private room is available because all semi-private or less expensive accommodations are occupied.
Since the evidence provided by the Employee in support of his claim does not establish that his confinement in a private room was due to a condition which required isolation for his own health or that of others, and because there is no indication that a semi-private room was unavailable, the Employer is not responsible for payment of the private room charges.
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Opinion of the Trustees
Based on the information in file, the Trustees, Trustee Combs dissenting, are of the opinion that the Employer is not responsible for the difference between the private and semi-private room rates for the Employee’s hospitalizations from January 28, 1983 through February 18, 1983, and from March 19, 1983 through April 2, 1983.