Opinion of Trustees
Resolution of Dispute
Case No. 88-495
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
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 coverage for inpatient treatment for alcoholism under the terms of the Employer Benefit Plan.
Background Facts
The Employee was admitted to a hospital’s chemical dependency unit on October 3, 1990 for detoxification and rehabilitation from chronic alcoholism. The Employee underwent routine detoxification with no medical complications. There is no indication that the inpatient treatment involved other medical or mental conditions.
HealthLink, an organization providing utilization review services for the Employer, had certified the Employee’s admission as “medically necessary” by letter dated October 4, 1990 to all parties involved. The letter states that such certification does not confirm eligibility for coverage or guarantee payment. The letter refers the Employee and the providers to the insurance company or the claims administrator for that information. HealthLink staff conducted routine monitoring throughout the Employee’s stay to confirm ongoing medical necessity. On October 29, 1990, HealthLink notified all parties involved that the confinement was no longer considered medically necessary and, therefore, no longer certified. The notice again stated that it was not a confirmation of eligibility or a guarantee of payment. The Employee was discharged from the hospital on October 30, 1990.
The Employer provided benefits for the first seven days of hospital confinement pursuant to Article III. A. (1)(f) of the Employer -Benefit Plan. The Employer has denied the Employee’s request for additional benefits.
Dispute
Employee
Employer
88-495 – May 6, 1992
Opinion of Trustees Resolution of Dispute Case No. 88-495
Page 2
Is the Employer required to provide benefits for more than seven days for the Employee’s inpatient treatment for alcohol dependency?
Positions of the Parties
Position of the Employee: The Employer Is required to provide benefits for the Employee’s inpatient treatment because it was certified as medically necessary by HealthLink.
Position of the Employer: The Employer is not required to provide benefits _for more than the first seven days of the Employee’s treatment because benefits for inpatient treatment of alcohol and drug abuse are limited to seven calendar days per admission under Article III. A. (1)(f) of the Employer Benefit Plan, and there is no indication that treatment of any other medical or mental condition was provided. The Employee and the providers were notified throughout the hospitalization that certification of medical necessity did not constitute a guarantee of payment.
Pertinent Provisions Article III. A. (1)(f) of the Employer Benefit Plan states:
(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.
…
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 seven calendar days per hospital admission. If inpatient treatment of a medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan.
The Employee In this case was hospitalized from October 3, 1990 to October 30 1990, for treatment of alcohol dependency. The records provided Indicate than the Employee underwent routine detoxification with no medical complications. There Is no indication in the record, nor
Opinion of Trustees Resolution of Dispute Case No. 88-495
Page 3
does the Employee allege, that inpatient treatment for other medical or mental conditions was required or provided during this hospital stay.
The Employee contends that because of the certification given by HealthLink, the additional days of hospitalization should be covered because they were deemed to be medically necessary. Both letters sent by HealthLink to the Employee and the providers clearly stated that certification of medical necessity does not confirm eligibility for coverage or guarantee payment, and that such information could be obtained by contacting the insurance carrier or claims administrator. There is no evidence that the Employee was otherwise advised that benefits could be paid beyond the first seven days of his hospital admission.
Inasmuch as the Employee received inpatient hospital care for alcohol dependency and the Employer has provided benefits for the first seven calendar days of the admission, the Employer Is not required to provide additional benefits under 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 inpatient treatment for alcohol dependency.