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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-165 – October 24, 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 provisions of health benefits coverage for inpatient treatment for alcoholism under the terms of the Employer Benefit Plan.
Background Facts
The Employee was treated for alcoholism at an inpatient rehabilitation facility from May 7, 1988 to July 8, 1988. The Employer has denied benefits for the Employee’s treatment because the facility is not an accredited hospital.
Dispute
Is the Employer required to provide benefits for the Employee’s inpatient treatment for alcoholism.
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits or the Employee’s inpatient treatment for alcoholism because such treatment is covered under the Employer Benefit Plan. The Employee also states that if he had had information concerning the accreditation requirement, he would have chosen an accredited establishment.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s inpatient treatment for alcoholism because the facility where the treatment was rendered is not an accredited hospital.
Opinion of Trustees Resolution of Dispute Case No. 88-165 Page 2
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 ram accommodations (including special diets and general nursing care) and a; 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.
Discussion
Opinion of Trustees Resolution of Dispute Case No. 88-165 Page 3
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 or emergency treatment for a maximum of 7 calendar days per admission. Article III. A. (1)(a) and (i) stipulate that the term “hospital” as used throughout the Plan refers to a hospital that is operated primarily for the purpose of rendering inpatient therapy for the several classifications of medical and surgical cases and that is approved by the Joint Commission on Accreditation of Hospitals (JCAH) or by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.
The Employer states that Summary Plan Descriptions containing the provisions cited above were made available to all employees, including the Complainant. The Employee in this case was admitted to an alcohol treatment facility for 60 days. The information provided indicates that the facility is not licensed as a hospital. In addition, this facility is not a JCAH-accredited hospital nor has it been approved a hospital by the Trustees of the 1950 Benefit Plan and Trust. Therefore, in this instance, the employer is not required to provide benefits for the Employee’s inpatient treatment for alcoholism.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s stay in rehabilitation facility for the treatment of alcoholism.