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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-846 – November 27, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for outpatient group therapy under the terms of the Employer Benefit Plan.
Background Facts
The Employee went to a community mental health center on March 29, 1993 “to learn how to deal with my drinking problem.” While there, he was examined and evaluated by two non-physician staff members at the center who then enrolled him in a substance abuse group therapy program.
On April 9, 1993, a physician at the mental health center conducted a comprehensive psychiatric evaluation, history and physical examination. The plan for the Employee was to complete the recommended outpatient treatment that included attending Alcoholics Anonymous (AA) meetings with a recommendation for outpatient psychiatric treatment if the Employee’s depression got worse.
The Employer denied benefits for the outpatient group therapy treatments, stating that the requirements of the Employer Benefit Plan were not met. In an affidavit signed December 22, 1994, the Employee maintains that attending AA only had not been successful and that other free services were not available. He further states that he had been evaluated by a physician and rehabilitation team before entering the group therapy program and was judged to be a good candidate for rehabilitation.
Dispute
Is the Employer required to provide benefits for the outpatient group therapy services rendered to the Employee?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the outpatient group therapy because AA had not been successful and other free care services were not available.
Position of the Employer: The Employer is not required to provide benefits for the outpatient group therapy because the Plan requirements were not met.
Pertinent Provisions
Article III A. (7) (f) states:
Article III Benefits
A. Health Benefits
(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 rehabilitation programs where free care sources are not available and when determined to be medically required by a physician.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental deficiencies.
3. School related behavioral problems.
4. Services by private teachers.
5. 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.
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
Discussion
Article III A. (7) (f) provides benefits for certain outpatient group therapy and alcoholism rehabilitation programs where free care sources are not available and the therapy has been
determined by a physician to be medically required. For patients with alcoholism, the Plan further requires advance determination that the patient is a good candidate for rehabilitation.
The Employee’s initial assessment at the center concluded that he was a good candidate for rehabilitation. While the follow-up examination and assessment by a physician came later, it was well within normal operating procedures for such centers. It is agreed by both sides in this dispute that the Employee had earlier tried AA, a generally available free service, but he found it not successful by itself. The physician treatment plan was for the Employee to complete the plan of the outpatient group therapy combined with AA meetings, and if the Employee’s depression became worse, it recommended outpatient psychiatric care as followup treatment.
The procedures followed being consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the outpatient group therapy services rendered to the Employee from March 29, 1993 through April 26, 1993.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the outpatient group therapy services rendered to the Employee from March 29, 1993 through April 26, 1993.