______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-660 – September 27, 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 chemical dependency treatment under the terms of the Employer Benefit Plan and hereby render their opinion on the matter.
Background Facts
The Employee’s dependent daughter was hospitalized for treatment for chemical dependency from April 14, 1987 to May 14, 1987. The Employee states that before his daughter was admitted to the facility, the manager of insurance and billing at the hospital called the Employer’s insurance carrier to verify coverage for his daughter’s hospitalization. The Employee claims that the carrier’s representative advised that coverage would be provided for 7 days of the inpatient hospitalization.
The Employer subsequently denied benefits for the hospitalization because the facility was not an accredited hospital.
The Employee asks whether the Employer is responsible for providing benefits for the first 7 days of his daughter’s inpatient chemical dependency treatment.
Dispute
Is the Employer responsible for providing benefits for the first 7 days of the Employee’s dependent’s inpatient chemical dependency treatment?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing benefits for the first 7 days of the Employee’s dependent’s inpatient chemical dependency treatment because it is a covered
Opinion of Trustees Resolution of Dispute Case No. 84-660 Page 2
benefit under the Employer Benefit Plan and the Employer’s insurance carrier had indicated that it would be covered prior to the admission.
Position of the Employer: The Employer is not responsible for providing benefits for the Employee’s dependent’s inpatient chemical dependency treatment because the facility was not an accredited hospital.
Pertinent Provisions
Article III. A. (1)(a), (f) and (i) of the Employer Benefit Plan state in pertinent part:
(1) Inpatient Hospital Benefits (a) Semi-private Room
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.
.. .
(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.
(i) General
Accredited Hospital is a hospital which is operated primarily for the purpose of rendering inpatient therapy for the several classifications of medical and surgical cases and which is approved by the Joint Commission on Accreditation of Hospitals or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.
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Discussion
Article III. A. (1)(f) of the Employer Benefit Plan provides benefits for emergency detoxification hospital care for the treatment of alcoholism or emergency treatment for drug abuse for up to 7 calendar days per inpatient hospital admission. Article III. A. (1) (a) and (i) stipulate that the term “hospital” as used throughout the Plan refers to a hospital that is approved by the Joint Commission on Accreditation of Hospitals (JCAH) or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.
Although the Employee claims that, prior to his daughter’s admission, hospital staff were advised that benefits would be paid for the first 7 days of his daughter’s hospitalization, there is no indication that either the Employee or the provider was misled regarding the coverage requirements of Article III. A. (1)(f) of the Plan. The information submitted indicates that the carrier’s representative discussed coverage available under the Employer Benefit Plan with the hospital’s staff, not whether the particular case met criteria for that coverage.
The Employer denied benefits for the Employee’s daughter’s hospitalization, stating that the hospital is not approved by the JCAH as a hospital operated primarily for the purpose of rendering in-patient therapy for several classifications of medical and surgical cases. While the facility in question is not accredited as a general hospital, it is a specialty hospital accredited by the JCAH, and licensed by the Ohio Department of Health, for the treatment of chemically dependent individuals.
Opinion of the Trustees
The Employer is responsible for providing medically necessary benefits for the Employee’s dependent’s first 7 days of inpatient chemical dependency treatment.