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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
93-017 – March 17, 2000
A. Frank Dunham, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for inpatient treatment under the terms of the Employer Benefit Plan.
Background Facts
On August 20, 1994, the Employee went to a hospital emergency room, saying he had had “nerves” and suicidal thoughts for several months. During the physician’s history and physical examination, it also was noted that he had been having severe crying episodes, was irritable and unable to sleep at night, and had excessive alcohol consumption in recent weeks. He was admitted the same evening to a chemical dependency treatment unit for detoxification.
He responded rapidly to various treatment modalities and continued to receive treatment for his depression and alcohol dependency until his discharge on August 30, 1994.
Initially, the admission was precertified for 30 days, because the primary diagnosis given to the Employer’s agent was major depression. When the medical documentation was reviewed later, the Employer provided benefits for seven days of detoxification and denied benefits for the last three days of the Employee’s hospitalization as beyond the seven calendar days allowed under the Plan for detoxification.
Dispute
Is the Employer required to provide benefits for the Employee’s hospitalization from August 28, 1994 through August 30, 1994?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s hospitalization because he was being treated for depression.
Opinion of Trustees ROD Case No. 93-017 Page 2
Position of the Employer: The Employer is not required to provide benefits for the extended hospitalization because the Employee Benefit Plan limits the provision of health benefits for inpatient treatment of alcoholism to seven calendar days.
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. . . .
Article III. A. (1) (e) states:
(1) Inpatient Hospital Benefits
(e) Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. When medically necessary, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period, (dating from the first day of hospital confinement, even if the first day of confinement occurred during a prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide inpatient hospital benefits.)
Article III. A. (1) (f) states in pertinent part:
(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.
Opinion of Trustees ROD Case No. 93-017 Page 3
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
The Introduction to Article III provides benefits for medically necessary services. Article III A. (1) (f) provides inpatient hospitalization benefits for a Beneficiary who requires emergency detoxification for the treatment of alcoholism for a maximum of seven calendar days per admission. If treatment of a medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan.
The Employee was admitted to an inpatient chemical dependency unit for 10 days for the treatment of alcohol dependency. The admission had initially been precertified for 30 days because the primary diagnosis was major depression. After review of the medical documentation, the Employer provided benefits for the first seven days of treatment, for detoxification, but denied payment for the remainder of the hospitalization.
A Fund’s medical consultant has reviewed the medical documentation submitted. The consultant notes that the Employee responded well to treatment, with no evidence of severe depression; was allowed a leave of absence on part of the day on the 26th and 27th, and showed no evidence of major depression at that time. The consultant further notes there is no documentation in the progress notes of the medical necessity of a stay beyond the allowed seven days for substance abuse. The consultant has concluded that the Employee could have been discharged within seven days and followed as an outpatient thereafter. Therefore, the Employer is not required to provide benefits beyond the seven calendar days provided under the Plan.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s stay beyond the seven days provided under the Plan.