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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
88-849 – March 6, 1996
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 emergency inpatient detoxification under the terms of the Employer Benefit Plan.
Background Facts
The Employee and his spouse were involved in an automobile accident in 1988 that left the Employee with residual pain and his spouse approximately three-quarters paralyzed. The record states that his wife blames the Employee for her medical condition although it is not clear that he was at fault in the accident. The Employee states that her attitude augmented his depression and feelings of guilt, which caused him to increase his alcohol consumption.
On July 9, 1991, the Employee sought help from his Employer’s Employee Health Advisory Program (EHAP) citing his depression and increasing alcohol consumption. He was advised to report to the EHAP the next day. After consultation there, he was referred to an area hospital where he was admitted to the inpatient detoxification unit. That evening, a routine detoxification regimen was begun following a telephone order from his physician. (The telephone order was signed by the doctor the following day.) He also received treatment and diagnostic studies for his chronic leg pain and depression. Nine days after admission, he was transferred to a comprehensive medical unit for continued treatment of his severe depression.
The Employer has provided benefits for the inpatient stay related to the Employee’s depression, but has denied benefits for the detoxification stay, stating that it was not an emergency admission.
Dispute
Is the Employer required to provide benefits for the Employee’s admission to the inpatient detoxification unit?
Positions of the Parties
Opinion of Trustees
ROD Case No. 88-849
Page 2
Position of the Employee: The Employer is required to provide benefits for the inpatient admission for detoxification because the admission was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the inpatient admission for detoxification because the admission was not an emergency.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states, in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. . . . Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
Article III (A) (1) (f) states: Article III Benefits
A. Health Benefits
(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.
Discussion
Opinion of Trustees
ROD Case No. 88-849
Page 3
The Introduction to Article III limits covered services to those services that are reasonable and necessary for the treatment of an illness or injury and are given at the appropriate level of care. Article III. A. (1) (f) provides that inpatient hospitalization for emergency detoxification for the treatment of alcoholism is a covered service, but limits the coverage to a length of stay of seven calendar days per inpatient hospital admission for this treatment.
A Funds’ medical consultant has reviewed the medical records for the inpatient period from July 10 to 19, 1991 and has concluded that the Employee’s admission to the hospital unit for detoxification was medically appropriate. Therefore, the Employer is required to provide benefits for seven of the nine days the Employee was in the detoxification unit. In the remaining two days of confinement, the Employee incurred charges of $820 for room and board and $32.10 for medications. The Employer is not required to provide benefits for room and board of $820, but is required to provide benefits for the $32.10 for medications, since these would have been medically appropriate regardless of the setting and are not affected by the seven-day inpatient treatment limitation.
Opinion of the Trustees
The Employer is required to provide benefits for seven of the days the Employee was an inpatient in the detoxification unit, is not required to provide benefits for room and board ($820.00) for the remaining two days but is required to provide benefits medications ($32.10) incurred in that period, since these would have been used regardless of the setting.