_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Employee
Employer
88-285 – July 25, 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 inpatient treatment for substance abuse under the terms of the Employer Benefit Plan.
Background Facts
Because of suicidal threats, the Employee’s dependent grandson was hospitalized from January 8, 1989 through January 30, 1989 under a medical detention order for substance abuse treatment. Following a hearing to evaluate his progress, he was transferred on January 30, 1989 under court order to an inpatient rehabilitation facility for extended treatment for substance abuse. The Employer has denied benefits for his treatment at the inpatient rehabilitation facility from January 30 until March 29, 1989 because the facility is not an accredited hospital and because the inpatient treatment rendered was not emergency detoxification and, therefore, is not covered under the Employer’s Health and Life Plan.
Dispute
Is the Employer required to provide benefits for the Employee’s dependent grandson’s stay in a chemical dependency treatment facility from January 30, 1989 through March 29, 1989?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s dependent grandson’s inpatient treatment for substance abuse because such treatment was medically necessary due to the severity of his alcohol problems.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s grandson’s stay in a chemical dependency treatment facility from January 30, 1989 through
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March 29, 1989, because the facility at which treatment was rendered is not an accredited hospital and because the treatment rendered was not emergency detoxification.
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.
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 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
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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.
On January 30, 1989, the Employee’s dependent grandson was transferred from a hospital to a chemical dependency treatment facility for adolescents for further treatment of a substance abuse problem. There is no evidence that the Employee’s grandson received emergency detoxification hospital care during his stay at the second facility. The information provided indicates that the facility does not satisfy the definition of a “hospital” set forth in Article III. A. (1)(i) of the Plan. The facility used in this case is not a JCAH-accredited hospital, and it has not been approved as 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 grandson’s inpatient treatment for substance abuse from January 30, 1989 through March 29, 1989.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s dependent grandson’s stay in a chemical dependency treatment facility from January 30, 1989 through March 29, 1989: