_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-245 – February 18, 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”) 1980 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 for travel expenses under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s 14 year old dependent daughter was referred by her attending physician to the West Virginia University Hospital for evaluation and treatment of large lumps in her neck. According to the Employee, the attending physician contacted the West Virginia University Hospital on October 28, 1985 and scheduled an appointment for the Employee’s daughter on November 8, 1985. Prior to obtaining this evaluation, the Employee’s daughter had been examined by her attending medical physician and a surgeon, neither of whom could determine the cause of the Employee’s daughter’s neck lumps.
The West Virginia University Hospital physician detected a cancerous thyroid in the Employee’s daughter, admitted her to the hospital on November 8, 1985, the same day of the exam, and operated two days later. The Employee did not seek prior approval for travel expenses but instead after the expenses were incurred, sought reimbursement for the travel expenses associated with his daughter’s November 1988 surgery and December 1988 post-operative hospitalization.
The Employer has denied reimbursement for the November and December 1988 travel expenses.
Dispute
Is the Employer responsible for providing payment for travel expenses for the Employee and his daughter?
Positions of the Parties
Position of the Employee: The Employee states that because of the urgency and severity of his daughter’s disease, he was not able to obtain prior approval before incurring the associated travel expenses for his daughter’s evaluation and hospitalization.
Position of the Employer: The Employer states that the Employee did not obtain prior approval or the travel expenses as required under Article III.A. (7)(e) of the Employer Benefit Plan.
Pertinent Provisions
Article 111.A. (7)(e) of the Employer Benefit Plan states:
(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.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or clinic for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
Discussion
Article III.A. (7)(e) of the Employer Benefit Plan provides benefits for transportation to an out-of-area medical center for medically necessary care which is not available near the Beneficiary’s home. Such transportation must be pre-authorized by the Plan Administrator.
Although the Employee’s daughter’s condition was severe, the Trustees have determined that the week between the time the appointment was scheduled and the time it took place allowed adequate time to seek prior approval for reimbursement of the travel expenses to the West Virginia University Hospital. No such request having been made, the conditions for coverage of travel expenses to an out-of-area facility have not been satisfied.
Opinion of the Trustees
The Employer is not responsible for the payment of the travel expenses relative to the Employee’s daughter’s out-of-area care at the West Virginia University Hospital in November and December of 1985.