_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-270 – October 12, 1990
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 treatment for substance abuse under the terms of the Employer Benefit Plan.
Background Facts
On November 1, 1989, the Employee’s daughter was admitted to a hospital for drug and alcohol detoxification. The hospital charges are not in dispute as they were paid by the Employer. Upon discharge from the hospital, the Employee’s daughter was admitted to a residential drug and alcohol treatment facility. The Employee paid the room and board charges and asked that the Employer pay the charges for treatment at the facility, which he characterized as outpatient in nature. The Employer has denied benefits for her treatment at the rehabilitation facility because the Employee’s daughter was treated on an inpatient basis, the charges were billed by the facility, and that facility is not an accredited hospital.
Dispute
Is the Employer required to provide benefits for the Employee’s daughter’s treatment at a residential drug and alcohol treatment facility?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing benefits for the treatment his daughter received because it was outpatient therapy.
Position of the Employer: The Employer is not required to pay the charges for the Employee’s daughter’s treatment at a residential drug and alcohol treatment facility because the treatment
Opinion of Trustees Resolution of Dispute Case No. 88-270 Page 2
was rendered on an inpatient basis, the charges were billed by the facility, and the facility is not an accredited hospital. Therefore, the charges are not covered under the Employer Benefit Plan.
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.
Article III. A. (7)(f) of the Employer Benefit Plan states:
Opinion of Trustees Resolution of Dispute Case No. 88-270 Page 3
(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.
Benefits are not provided for:
- Encounter and self-improvement group therapy.
- Custodial care related to mental retardation and other mental
deficiencies.
- School related behavioral problems.
- Services by private teachers.
- Alcoholism and drug rehabilitation if an advance determination
has not been made by the rehabilitation team that the Beneficiary is
a good candidate for rehabilitation.
- Alcoholism and drug rehabilitation programs not approved by
Medicare.
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 drug abuse for a maximum of 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 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.
After receiving inpatient detoxification care for an alcohol and drug dependency problem, the Employee’s daughter was admitted to a residential treatment facility for extended treatment for substance abuse. The Employee is seeking payment for the therapy his daughter received, which he claims was outpatient treatment, but not for the room and board charges at the rehabilitation facility. Although outpatient treatment is provided under Article III. A. (7)(f), the Employee’s daughter’s therapy was rendered in and by the facility at which she resided and was not outpatient treatment. Thus, Article III. A. (7)(f) does not apply in this instance. The rehabilitation facility is not a JCAH-accredited hospital, nor has it been approved as a hospital
Discussion
Opinion of Trustees Resolution of Dispute Case No. 88-270 Page 4
by the Trustees of the 1950 Benefit Plan and Trust. Therefore, the facility does not satisfy the definition of a “hospital” set forth in Article III. A. (1)(i) of the Plan.
Inasmuch as the Employee’s daughter’s treatment was on an inpatient basis and the facility does not meet the requirements of the Employer Benefit Plan for coverage, the Employer is not required to provide benefits for the treatment under the terms of the Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s daughter’s treatment at a residential drug and alcohol treatment facility.