_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Employee
Employer
84-614 – June 6, 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 alcoholism and drug rehabilitation services under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was hospitalized in the alcohol and chemical dependency treatment unit of a hospital from March 13, 1987 to April 24, 1987. The hospital discharge summary states that her principal diagnosis was alcohol dependency syndrome with a secondary diagnosis of polydrug abuse and a complication of depression. The Employee claims that before his spouse entered the program, he and a representative of the hospital billing department independently called the Plan Administrator to inquire about coverage for the hospitalization. He alleges that they were both told that the charges for the hospitalization would be paid in full by the Employer. The Employee claims that the Employer advised the representative of the hospital billing department that benefits would be provided for 7 days of inpatient treatment for alcoholism and drug abuse; the hospital would need to bill for an additional medical problem, such as stress and depression, in order for the Employer to provide additional benefits.
The Employee’s wife states that depression and stress brought on her alcoholism. She also states that after a few weeks of treatment she was evaluated by a psychiatrist who began treating her for depression. She contends that the hospital billed the insurance carrier incorrectly fur treatment of alcoholism and drug abuse and that the hospital refused to resubmit the bill as charges for treatment of stress and depression.
The Employer originally paid the charges for the Employee’s spouse’s entire hospitalization, minus personal items. During a routine audit of claims, it determined that under Article III. A. (1)(f) of the Plan, benefits for inpatient hospitalization for alcohol detoxification are limited to 7 calendar days. Based on the diagnosis of “alcohol dependency, multiple drug dependency,” as stated on the hospital bill, the Employer denied benefits for the Employee’s spouse’s
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hospitalization beyond the 7 calendar days specified under the Plan. The Employer requested and received a refund from the hospital of amount denied.
Dispute
Is the Employer responsible for payment of the charges for the Employee’s spouse’s inpatient hospitalization for alcohol and drug detoxification and treatment beyond March 19, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the charges for the Employee’s spouse’s inpatient hospitalization beyond March 19, 1987, because she was being treated for depression and stress in addition to her alcohol and drug dependency.
Position of the Employer: The Employer is not responsible for payment of the charges for the Employee’s inpatient treatment beyond March 19, 1987, because Article III. A. (1)(f) of the Employer Benefit Plan limits the provision of health benefits for inpatient treatment of alcoholism or drug abuse to 7 calendar days.
Pertinent Provisions Article III. A. (1)(e) and (f) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits (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).
(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.
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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 required by a physician.
Benefits are not provided for:
- Encounter and self-improvement group therapy.
- 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 hospitalization benefits for a Beneficiary who requires emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of 7 calendar days per admission. If treatment of a medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan. Article III. A. (1)(e) of the Employer Benefit Plan provides inpatient hospitalization benefits for a Beneficiary who is confined for treatment of mental illness. In addition, Article III. A. (7)(f) of the Employer Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
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The Employee’s spouse was admitted to an inpatient alcohol and chemical dependency treatment (ACT) unit for 42 days for treatment of alcohol and drug dependency. The Employer paid the charges for the first 7 days of treatment, but denied payment for the remainder of the hospitalization. Although the Employee’s spouse contends that her hospitalization should be covered in full because she was treated for stress and depression, there is no evidence that, following detoxification, she required inpatient confinement for treatment for mental illness, for which benefits may be provided under Article III. A. (1)(e) of the Plan. Rather, the treatment provided the Employee’s spouse in the ACT unit was designed for alcohol/chemical dependent patients and is based on a multidisciplinary approach which included medical detoxification, individual counseling, Alcoholics Anonymous meetings, psychiatric evaluation and treatment, physical therapy, recreation therapy and other services. Furthermore, because the treatment was rendered in an inpatient (rather than outpatient) program, the Employer is not responsible for providing health benefits under Article III. A. (7)(f). Inasmuch as the Employee’s spouse received inpatient hospital care for the treatment of alcohol and drug dependency, the Employer is not responsible for providing inpatient hospitalization benefits beyond those paid for the Employee’s spouse’s hospitalization from March 13, 1987 through March 19, 1987, consistent with the terms of Article III. A. (1)(f) of the Plan.
Opinion of the Trustees
The Employer is not responsible for the provision of any additional benefits for the Employee’s spouse’s hospitalization for treatment of alcohol and drug dependency.