_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-341 – January 9, 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 benefits for an Employee’s son’s inpatient treatment for alcohol dependency under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son was treated in a hospital-based inpatient chemical dependency rehabilitation program from May 30, 1990 to June 21, 1990. According to the hospital discharge summary, the principal diagnosis was alcohol and nicotine dependencies with mixed substance abuse. The Employee’s son’s treatment plan included detoxification, individual and group milieu therapy, written and verbal assignments, Alcoholics Anonymous/Narcotics Anonymous meetings and family education workshops.
The Employer provided coverage for the Employee’s son’s entire hospitalization; however, a portion of the daily room charges was paid at a rate of 80%, leaving a balance of $1,000. The Employer has denied the Employee’s request for additional benefits, stating that coverage for inpatient substance abuse treatment is limited to a 7-day period under the Employer Benefit Plan, and the amount already paid by its insurance carrier has far exceeded that limitation.
Dispute
Is the Employer required to provide additional benefits under the Employer Benefit Plan for the Employee’s son’s inpatient treatment for alcohol dependency?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-341 Page 2
Position of the Employee: The Employer is required to provide additional benefits for the Employee’s son’s inpatient treatment for alcohol dependency because such treatment should be covered in full under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide additional benefits for the Employee’s son’s inpatient treatment for alcohol dependency because the Employer Benefit Plan limits coverage for such treatment to 7 calendar days per admission, and the amount paid by the Employer’s insurance carrier has far exceeded that limitation.
Pertinent Provisions Article III. A. (1)(f) of the Employer Benefit Plan provides:
(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 provides in pertinent part: (7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addition 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.
Opinion of Trustees Resolution of Dispute Case No. 88-341 Page 3
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. If inpatient treatment of a different medical or mental condition is necessary following detoxification, 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.
The Employee’s son in this case was hospitalized from May 30, 1990 until June 21, 1990 for treatment of alcohol dependency. The records provided indicate that the rehabilitation program was administered in two phases. Phase I consisted of clinical assessment, medical stabilization and detoxification. Phase II consisted of school and therapeutic sessions, including individual therapy, group therapy, family workshops and relaxation sessions. There is no indication in the record nor does the Employee allege that inpatient treatment for other medical or mental conditions was required during this admission. Inasmuch as the Employee’s son received inpatient hospital care for alcohol dependency, and the Employer has provided benefits for more than seven calendar days of this admission, the Employer is not required to provide additional benefits, consistent with the terms of Article III. A. (1)(f) of the Plan.
Opinion of the Trustees
The Employer is not required to provide additional benefits for the Employee’s son’s inpatient treatment for alcohol dependency.