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OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee and Donald E. Pierce, 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 provision of benefits coverage for mental illness under the terms of the Employer Benefit Plan and hereby render their opinion on the matter.
Background Facts
The Employee’s spouse was confined in a hospital for mental illness for the following periods: October 4, 1982 through October 28, 1982; April 28, 1983 through May 27, 1983, June 19, 1983 through June 25, 1983 and May 7, 1984 through June 14, 1984. The total number of days of hospitalization billed for during these admissions is ninety-seven (97).
The Employer has paid for all periods of confinement except for seven (7) days: June 8, 1984 through June 14, 1984.
Dispute
Is the Employer responsible for payment of charges for hospitalization for mental illness from June 8, 1984, through June 14, 1984?
Position of Parties
Position of Employee: The Employer should pay the charges for the Employee’s spouse’s hospitalization for the periods from June 8, 1984, through June 14, 1984, especially since a consulting physician provided care to the patient during the May 7, 1984, through June 14, 1984 admission.
Employee
Employer
81-598 – June 24, 1985
Opinion of Trustees Resolution of Dispute Case No. 81-598 Page 2
Position of Employer: The Employee’s spouse was confined for more than 90 days for mental illness in the two-year period prior to June 8, 1984; therefore, she was not eligible for benefits for the period June 8, 1984, through June 14, 1984.
Pertinent Provisions
Article III. A. (1) (e) of the Employer Benefit Plan which provides:
e. Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. When medically necessary, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short- term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period (dating from the first day of hospital confinement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide inpatient hospital benefits.)
Question and Answer (“Q&A”) #81-6, states: Question:
The inpatient hospital benefit for mental illness limits the number of covered days as follows:
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. Subject to the approval by the Trustees, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period (dating from the first day of hospital confinement> is deemed for purposes of the Plan to be a chronic (long-term) mental problem for which the Trustees will not provide inpatient hospital benefits.)
How is the limit of “90 days over a two-year period” to be interpreted? Answer:
The limit refers to the cumulative number of days of inpatient hospital care for all mental illness diagnoses, without regard to each acute episode.
The two-year period begins on the first day of an inpatient hospital stay for a mental problem and ends two full years later.
Opinion of Trustees Resolution of Dispute Case No. 81-598 Page 3
Discussion
Under Article III. A. (1) (e) of the Employer Benefit Plan, benefits are not provided for inpatient hospital confinements for chronic mental illness. An individual is deemed to have chronic mental illness if he/she is confined for more than 90 days over a two-year period, dating from the first day of hospital confinement. According to Q&A #81-6, the limit of “90 days over a two year period” is interpreted as the cumulative number of days of inpatient hospital care for all mental illness diagnoses, without regard to each acute episode.
The information submitted to the Trustees indicates the Employee’s spouse was confined in a hospital for mental illness for more than 90 days during the two-year period following her first day of confinement in October 1982. Therefore, the spouse is deemed to have chronic mental illness.
The Employee has contended that the days on which his spouse received care for another illness, from other than her attending physician, during the May 7 through June 14, 1984 hospital admission, fall under other coverage provisions of the Plan and, therefore, should not be considered in calculating her eligibility for benefits under the inpatient mental illness benefit. Because the consulting physician was called in during this patient’s hospitalization for mental illness to provide only limited care for a skin condition, this factor has no bearing on the Employee’s spouse’s eligibility limitation for inpatient mental illness benefits, nor does it alter the reason for her admission.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for providing in-patient hospital benefits for the Employee’s spouse for the period from June 8, 1984, through June 14, 1984.