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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-457 – January 5, 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 confinement for mental illness under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has had multiple hospital admissions for treatments of her mental condition (multiple personality and atypical depression). The Employer paid benefits for 90 days during a two year period and denied benefits for confinement after the 90 days. The Employee states that he did not know about the 90-day limitation.because he was never given a Plan booklet.
Dispute
Is the Employer responsible for payment of health benefits for the Employee’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years?
Positions of the Parties
Position of the Complainant: The Employer is responsible for payment of health benefits for the Employee’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years because the Employer did not give the Employee a copy of the Employer Benefit Plan; therefore, the Employee did not know of the limitation on coverage.
Position of the Respondent: The Employer is not responsible for payment of hearth benefits for the Employee’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years. The Company’s 1984 Plan Booklet was provided to every active Employee at the mine site. The Employee’s spouse’s illness is a long-term mental problem for which inpatient hospital benefits are not provided under the Plan.
Opinion of Trustees Resolution of Dispute Case No. 84-457 Page 2
Pertinent Provisions Article III. A. (I) (e) of the Employer Benefit Plan states:
(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, even if the first day of confinement occurred during a prior Wage Agreement) 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).
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 a chronic mental problem if he/she is confined for more than 90 days over a two-year period, dating from the first day of hospital confinement. The Employer has denied benefits for the Employee’s spouse’s inpatient hospital confinements which exceed the 90-day limitation set forth in Article III. A. (1) (e).
The Employee states that he did not receive a Plan booklet and was unaware of the limitation on coverage for long-term in-patient hospitalization. He contends that no one notified him of the limitation in time to prevent bills for services beyond that period being incurred. He stated to a Funds’ staff member that he worked by himself at the water treatment part of the mine and was perhaps unaware when Plan booklets were passed out. He is not sure exactly how other Employees received theirs and was unaware that he needed one.
The Employer states that every Employee was provided a 1984 Plan booklet. Two classified workers employed at the time of the 1984 Plan distribution have described to Funds’ staff the procedure followed by the Employer. They stated that three different booklets were distributed, stapled to their pay checks. They said if an Employee had to go to the benefits office to get his check, they felt certain the booklets would still have been stapled to the check since the assemblage of the checks with the booklets was handled at that office. Further, they stated that all Employees are usually aware of something special being distributed and would normally ask for their copies of whatever the other men are receiving. Given the miners’ description of the Employer’s distribution of the Employer Benefit Plan, we conclude that the Employee was furnished with a 1984 Plan booklet which details the 90-day limitation over a two-year period on benefits for hospitalization for mental illness.
Opinion of Trustees Resolution of Dispute Case No. 84-457 Page 3
Opinion of the Trustees
The Employer has fulfilled its responsibility to provide coverage for inpatient confinement for mental illness.