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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-093 – September 25, 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 benefits for travel and lodging expenses incurred by a Beneficiary’s escort under the terms of the Employer Benefit Plan.
Background Facts
In April 1988, the Employee’s five-year-old son was referred out-of-area to Shriner’s Hospital in Greenville, South Carolina, for treatment of Legg-Calvé-Perthes disease, an inflammation of the bone and cartilage surrounding the upper end of the femur. The Employee lives in Appalachia, Virginia, which is 188 miles from Greenville.
On June 8, 1988, the Employee and his spouse transported their son to Shriner’s Hospital. The child was hospitalized from June 8, 1988 through July 2, 1988. The Employee’s spouse stayed at a hotel in Greenville, South Carolina during the child’s hospitalization, and she made daily trips from the hotel to the hospital to be with her son. On the day the child was discharged, July 2, 1988, his mother drove him home to Virginia.
The Employer has reimbursed the Employee for travel expenses between Virginia and South Carolina. The Employee has requested additional reimbursement for his spouse s lodging expenses and her local transportation expenses incurred in Greenville during their son’s hospitalization. The Employer has denied benefits for these additional expenses.
Dispute
Is the Employer required to pay the Employee’s spouse’s expenses for lodging and daily trips to the hospital during the Employee’s son’s stay in an out-of-area hospital?
Positions of the Parties
Position of the Employee: The Employer is required to pay the Employee’s spouse’s expenses for lodging and daily trips to the hospital because it was necessary that she be with her son while he was hospitalized.
Position of the Employer: The Employer is not required to pay the Employee’s spouse’s expenses for lodging and daily trips to the hospital because no evidence was submitted to indicate that an escort’s presence was necessary during the child’s hospitalization.
Pertinent Provisions
Article III. A. (7)(e) of the Employer Benefit Plan states:
(7) Other Benefits
(e) Ambulance and Other Transportation
Benefits are provided for ambulance transportation to or from a hospital, clinic, medical center, physician’s office, or skilled nursing care facility, when considered medically necessary by a physician.
With prior approval from the Plan Administrator benefits will also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out-of-area medical center.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or clinic for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
Q&A 81-8 states:
Subject: Lodging Costs for a Family Member’s Stay
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (1) (a), A (7) (e), and A (11) (a) 9
Question:
1. Are benefits provided for hospital room and board costs resulting from a family member’s stay with a hospitalized Beneficiary, when the attending physician considers the family member’s stay to be medically necessary?
2. When a Beneficiary qualifies for travel benefits under Article III, Section A (7) (e) of the Plan, are benefits provided for lodging costs for the escort, when the attending physician considers the escort to be medically necessary?
Answer:
1. No.
2. Yes, but only if the use of an escort has received the prior approval of the Plan Administrator. If the patient’s length of stay at an out-of-area facility is so long that it would be impractical for the escort to remain until the patient can travel to his/her home, the escort will be reimbursed for the cost of two round trips.
Discussion
Article III. A. (7)(e) 1. of the Employer Benefit Plan provides benefits for transportation to an out-of-area medical center if the needed medical care is not available near the Beneficiary’s home. Q&A 81-8 states that, when a Beneficiary qualifies for travel benefits under Article III. A. (7)(e) of the Plan, benefits are also provided for an escort’s lodging costs when the attending physician considers the escort to be medically necessary. Q&A 81-8 also indicates that “[i]f the patient’s length of stay at an out-of-area facility is so long that it would be impractical for the escort to remain until the patient can travel to his/her home, the escort will be reimbursed for the cost of two round trips.
The Employee’s spouse has requested reimbursement for her lodging costs during the 24 days that she stayed in Greenville, South Carolina. There is no indication that it was necessary for the Employee’s spouse to remain in Greenville throughout the 24-day hospitalization. Twenty-four days is an impractically long stay, and the Employer properly reimbursed the Employee for the cost of two round trips. The Employer is not required to provide additional benefits for the Employee’s spouse’s lodging expenses.
The Employee’s spouse has also requested reimbursement for her local transportation expenses during her son’s hospitalization. Article III. A. (7)(e) of the Employer Benefit Plan limits coverage for transportation expenses to four situations: (1) ambulance transportation; (2) transportation of a beneficiary to an out-of-area medical center; (3) frequent transportation of a beneficiary between his home and a hospital or clinic for specialized treatment; and (4) transportation of an escort who must accompany a beneficiary during transportation. The Employee’s spouse’s transportation from her motel to the hospital is not the type of transportation for which benefits are provided under Article III. A. (7)(e). The Employee’s spouse was not accompanying her son when she traveled from her motel to the hospital; accordingly, those trips are not covered.
Opinion of the Trustees
The Employer is not required to pay the Employee’s spouse’s expenses for lodging and daily trips to the hospital during the Employee’s son’s stay in an out-of-area hospital.