Opinion of Trustees
Resolution of Dispute
Case No. 84-686
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-686 – March 22, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 hospitalization under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was hospitalized in a psychiatric facility for 35 days, from July 18, 1986 to August 22, 1986. The hospital discharge summary states that her admitting diagnosis was major depression, single episode. On September 16, 1986, the attending psychiatrist stated that the Employee’s spouse developed severe bronchitis and a pneumonia-like illness and was bedridden for the last several days of her stay. During this period she was treated with antibiotics by an internist, and her psychotherapy and treatment with psychotropic drugs were suspended. The Employee’s spouse recovered from this illness and was to resume her psychiatric treatment when she demanded to be discharged, against the medical advice of her psychiatrist. The attending psychiatrist later stated that the Employee’s spouse had not achieved the maximum benefit from her hospitalization at the 30-day point of her stay, and acute medical complications warranted continued in-patient care.
The Employer provided coverage for the first thirty (30) days of the Employee’s spouse’s hospitalization in a psychiatric facility, but it denied coverage for the last 5 days of her stay.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s hospitalization in a psychiatric facility for more than 30 days?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 84-686
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Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s hospitalization in a psychiatric facility for more than 30 days because extended hospitalization was deemed medically necessary by the patient’s doctor.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s hospitalization in a psychiatric facility for more than 30 days because continued treatment on an inpatient basis was not medically necessary for the treatment of her mental illness or medical complications.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in pertinent part:
Article III – Benefits
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (1)(e) 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).
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services are limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care. The Introduction further states that the fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under the Plan.
Opinion of Trustees Resolution of Dispute Case No. 84-686
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Article III. A. (1)(e) of the Plan states that benefits are provided for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist for up to a maximum of 30 days. It further states that, when medically necessary, hospitalization for an acute (short-term) mental illness may be extended for a maximum of 30 additional days per episode of acute illness.
The Employee’s spouse was hospitalized in a psychiatric facility for 35 days. The Employer paid the charges for the first 30 days of treatment but denied payment for the remainder of the hospitalization as not medically necessary.
The Employee’s spouse contends that an extended period of hospitalization was medically necessary due to her medical condition and/or to an acute episode of mental illness. Article III. A. (1)(e) states only that when medically necessary for an acute mental illness, hospitalization may be extended. Article III. A. (1)(e) does not state that hospitalization for mental illness may be extended when medically necessary due to any other illness. It is not necessary to decide that issue in this case because the Employee’s spouse’s physical illness did not necessitate hospitalization. The Employee’s spouse became weak and nauseous during the last several days of hospitalization. Her attending psychiatrist consulted an internist concerning these symptoms. The discharge summary indicates that the internist diagnosed her condition as rhinopharyngitis (inflammation of the mucous membrane of the nose) and thrombocytopenia (abnormal decrease in the number of blood platelets). She was treated conservatively for this condition. A Funds’ medical consultant reviewed the file and advised that the Employee’s spouse’s condition did not require extended hospitalization.
The evidence also does not establish that extended hospitalization was necessary due to the Employee’s spouse’s mental illness. The admitting diagnosis was major depression, single episode. During the last several days of her hospitalization, her psychiatric treatment was extremely limited. The attending psychiatrist has not stated that extended hospitalization was medically necessary due to mental illness. He stated only that the Employee’s spouse had not met “maximum hospital benefit” after 30 days of hospitalization. A Funds’ medical consultant has reviewed the file and determined that the Employee’s spouse’s mental illness did not necessitate extended hospitalization. The consultant advised that continued psychiatric care could have been provided on an outpatient basis.
Opinion of the Trustees
The Employer is not required to provide benefits for more than 30 days of the Employee’s spouse’s hospitalization for acute mental illness, nor for the 5 days of inpatient treatment of medical symptoms which did not require hospitalization.