______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-157 – June 24, 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 health benefits coverage for inpatient alcoholism and drug detoxification services under the terms of the Employer Benefit Plan.
Background Facts
The Employee was diagnosed as being chronically and acutely addicted to alcohol and other drugs. After an evaluation indicated that he was an excellent candidate for inpatient detoxification and treatment, the Employee was admitted to a hospital’s inpatient alcoholism and drug dependency treatment unit. The Employee went through emergency detoxification and then stayed in the hospital to complete a four-week program conducted by the treatment unit.
The Employer’s insurance carrier initially made payment for the first nine days of the hospital stay. The insurance carrier then discovered that it had not established that the inpatient care was for emergency treatment, retrieved the payment, confirmed the emergency nature of the services, and paid $2,680.50 for the first seven days of the four-week program. The Employer maintains that it is responsible for payment of only up to seven days of hospitalization for emergency detoxification, and that the $5,235.10 balance of the $7,915.60 hospital bill is the responsibility of the Employee.
Question or Dispute
Is the Employer responsible for payment of the charges for the Employee’s inpatient hospitalization for drug and alcohol detoxification and treatment?
Position of the Parties
Position of the Employee: The Employer is responsible for the entire cost of the inpatient stay because all requirements of the Employer Benefit Plan were met.
Opinion of Trustees Resolution of Dispute Case No. 84-157 Page 2
Position of the Employer: The Employer is not responsible for payment of charges incurred after the first seven days of inpatient treatment because the Employer Benefit Plan provides health benefits for a maximum of seven calendar days of emergency detoxification. After the first seven days, benefits are provided only for outpatient services for alcoholism treatment or drug rehabilitation when medically necessary.
Pertinent Provisions Article III A (1) (f) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(f) Alcoholism and Drug Abuse
Benefits are provided for a Beneficiary who requires emergency detoxification hospital care for the treatment of alcoholism or emergency treatment for drug abuse. Such treatment is limited to 7 calendar days per inpatient hospital admission.
If treatment of a medical or mental condition is necessary following detoxification or emergency treatment for drug abuse, benefits may be provided under other provisions of this Plan and are subject to any requirements or limitations in such provisions.
See paragraph (7) (f) for information concerning other services related to treatment of alcoholism and drug abuse.
Article III A (7) (f) of the Employer Benefit Plan states: (7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addiction Benefits are provided for:
Psychotherapy, psychological testing, counseling, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically necessary by a physician.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
Opinion of Trustees Resolution of Dispute Case No. 84-157 Page 3
- Custodial care related to mental retardation and other mental deficiencies.
- School related behavioral problems.
- Services by private teachers.
- Alcoholism and drug rehabilitation if an advance determination has not been made by the rehabilitation team that the Beneficiary is a good candidate for rehabilitation.
- Alcoholism and drug rehabilitation programs not approved by Medicare.
Discussion
Article III. A. (1) (f) of the Employer Benefit Plan provides inpatient benefits for emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of seven calendar days per admission. If treatment of a different medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan. In addition, Article Ill. A. (7) (f) of the Employer Benefit Plan provides outpatient benefits for treatment of alcoholism or drug abuse.
The Employee was admitted to a hospital for emergency detoxification and treatment for drug and alcohol use. The Employer’s insurance carrier endorsed the admission under the terms of the Employer Benefit Plan. The Employer is therefore responsible for the provision of health benefits coverage for the inpatient hospital stay for emergency detoxification for a maximum of seven calendar days. There is no evidence that, following detoxification, the Employee required inpatient care and treatment for any other medical or mental condition for which benefits are provided under other provisions of the Plan, or that the Employee received any outpatient services described in Article III. A.(7) (f).
Opinion of the Trustees
The Employer is responsible for providing health benefits coverage for the first seven calendar days of the Employee’s emergency inpatient hospitalization for alcoholism and drug abuse, but is not responsible for paying inpatient hospital benefits beyond the seventh day.