Opinion of Trustees
Resolution of Dispute
Case No. 84-723
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-723 – February 28, 1991
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 for inpatient treatment for drug abuse for an Employee’s spouse under the term; of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was hospitalized from November 20, 1986 until December 18, 1985 for treatment of addiction to a prescription drug. The Employer provided benefits for the first 7 days of the Employee’s spouse’s hospitalization, but denied benefits for the remainder of the stay, stating that under the Employer Benefit Plan, benefits are provided for up to 7 days for emergency inpatient treatment for alcoholism and drug abuse. In a letter dated August 30, 1990, a physician affiliated with the hospital’s substance abuse services states that the Employee’s spouse’s prospect for recovery would have been greatly reduced had she been hospitalized for only 7 days, and therefore, a longer period of hospitalization was medically necessary.
Dispute
Is the Employer required to provide benefits for more than the first 7 days of the Employee’s spouse’s inpatient treatment for drug abuse:
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the entire period of the Employee’s spouse’s inpatient treatment for drug abuse because a physician determined that an extended stay was medically necessary,
Position of the Employer: The Employer is not required to provide benefits for more than the first 7 days of the Employee’s spouse’s treatment because benefits for inpatient treatment of alcohol and drug abuse are limited to 7 calendar days per admission under Article III. A. (1)(f) of
Opinion of Trustees Resolution of Dispute Case No. 84-723
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the Employer Benefit Plan, and there is no indication that treatment of any other medical or mental condition was provided.
Pertinent Provisions Article III. A. (1)(f) of the Employer Benefit Plan states:
(1) 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.
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 in pertinent part (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.
Discussion
Article III. A. (1)(f) of the Employer Benefit Plan provides benefits for inpatient treatment of alcoholism and drug abuse when a Beneficiary requires emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of T calendar days per admission. If inpatient treatment of a medical or mental condition is necessary following detoxification or emergency treatment for drug abuse, benefits may be payable under other provisions of the Plan. In addition, Article III. A. (7)(f) of the Employer Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
Opinion of Trustees Resolution of Dispute Case No. 84-723
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The Employee’s spouse was hospitalized from November 20, 1986 until December 18, 1986 for treatment of addiction to a prescription drug. The Employer paid the charges for the first 7 days of treatment, but denied payment for the remainder of the hospitalization. A physician affiliated with the hospital’s substance abuse services has stated that hospitalization beyond the first 7 days was medically necessary to improve the Employee’s spouse’s prospects for recovery. A Funds’ medical consultant has reviewed this case and has advised that the documentation provided indicates that the inpatient admission in this case was for treatment of drug abuse. According to the consultant, there is no documentation that inpatient care was required for treatment of other medical or mental conditions during this admission. Inasmuch as the Employee’s spouse received inpatient hospital care for the treatment of drug abuse, the Employer is not required to provide benefits for services rendered beyond the first 7 days of the Employee’s spouse’s hospitalization, consistent with the terms of Article III. A. (1)(f) of the Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for more than 7 days of the Employee’s spouse’s hospitalization for treatment of drug abuse.