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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-237 – March 8, 1987
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 benefits for ambulance transportation to an out-of-area medical center under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was referred by a gynecologist to an out-of-area medical center, the Johns Hopkins University Hospital, for treatment of a chronic skin disorder, the symptomatology of which caused the patient intractable itching and burning of the vulva and perineum. The Employee’s spouse requested prior approval for ambulance transportation to Johns Hopkins University Hospital on the basis that she was not able to sit up for more than 48 minutes at a time. Prior approval was denied on the grounds that ambulance transportation was not medically necessary. Thereupon, the Employee’s spouse travelled by station wagon to Johns Hopkins. Though no ambulance charge was incurred, the Employee’s spouse contends that ambulance services should be covered because she met the medical necessity test.
Dispute
Is the Employer responsible for providing benefits for ambulance transportation to the Johns Hopkins University Hospital for the Employee’s spouse?
Position of the Parties
Position of the Employee: The Employee contends that the ambulance transportation was medically necessary and therefore a covered benefit.
Position of the Employer: The Employer contends that the ambulance transportation was not medically necessary and therefore was not a covered benefit.
Pertinent Provisions
Article Ill. A. (7) (e) of the Employer Benefit Plan states in part:
(7) Other Benefits
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a hospital, clinic, medical center, physician’s office, or skilled nursing care facility, when considered medically necessary by a physician. With prior approval from the Plan Administrator, benefits will also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out of area medical center.
Discussion
Article III. A. (7) (e) of the Employer Benefit Plan states that benefits are provided for medically necessary ambulance transportation. Although prior approval is not required for ambulance transportation, the Employer may require that medical necessity be established. In response to an inquiry from the Plan Administrator in this case, the referring physician stated that ambulance transportation to the Johns Hopkins University Hospital was not medically necessary. Two other physicians who saw the Employee’s spouse prior to her referral failed to produce documentation supporting the medical necessity of ambulance transportation when the Plan Administrator requested that they do so. As medical necessity for the ambulance transportation was not established, the Employer properly denied prior approval of this service.
Opinion of the Trustees
The Employer is not responsible for providing benefits for ambulance transportation for the Employee’s spouse.