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OPINION OF TRUSTEES _____________________________________________________________________________

In Re

Complainant: Respondent: ROD Case No:

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.

Pursuant to Article IX of the United Mine Workers of America 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 mental illness.

Background Facts

The Employee’s spouse was confined in a hospital for mental illness for the following periods: May 9, 1978 through June 1, 1978, July 10, 1978 through July 26, 1978, March 2, 1979 through March 16, 1979, October 18, 1979 through November 7, 1979, December 8, 1979 through December 21, 1979, January 28, 1980 through February 8, 1980, March 23, 1980 through April 11, 1980, May 12, 1980 through May 31, 1980, November 22, 1980 through December 5, 1980, May 8, 1981 through June 8, 1981, July 1, 1981 through July 22, 1981, and August 31, 1981 through September 30, 1981. The Employer has paid for all periods of confinement except July 1, 1981 through July 22, 1981 and August 31, 1981 through September 30, 1981.

Dispute

Is the Employer responsible for payment of charges for hospitalization for mental illness from July 1, 1981 through July 22, 1981 and August 31, 1981 through September 30, 1981?

Position of Parties

Position of Employee’s Representative: Days for which benefits are provided for treatment of mental illness under the 1978 Employer’s Benefit Plan should not be counted in determining eligibility for such benefits under the 1981 Employer’s Benefit Plan. Therefore, the Employer should be required to pay the charges for the Employee’s spouse’s hospitalization for the periods from July 1, 1981 through July 22, 1981 and August 31, 1981 through September 30, 1981.

Position of Employer: The Employee’s spouse had more than 90 days of confinement for mental illness in the two-year periods prior to July 1, 1981, and August 31, 1981, and, therefore, was not

Employee
Employer
81-24 – June 28, 1983

Opinion of Trustees Resolution of Dispute Case No. 81-24
Page 2

eligible for benefits for the periods from July 1 1981 through July 22, 1981 and August 31, 1981 through September 30, 1981.

Pertinent Provisions
Article III. A. (1) (e) of the Employer’s Benefit Plan which provides:

(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) 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.)

Question and Answer (“Q&A”) #81-6, adopted by the Trustees, provides: Question:

The inpatient hospital benefit for mental illness limits the number of covered days as follows:

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. Subject to the approval by the Trustees, 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) is deemed for purposes of the Plan to be a chronic (long-term) mental problem for which the Trustees will not provide inpatient hospital benefits.)

How is the limit of “90 days over a two-year period” to be interpreted? Answer:

The limit refers to the cumulative number of days of inpatient hospital care for all mental illness diagnoses, without regard to each acute episode.

The two-year period begins on the first day of an inpatient hospital stay for a mental problem and ends two full years later.

Opinion of Trustees Resolution of Dispute Case No. 81-24
Page 3

Discussion

Under Article III.A(1)(e) of the Employer’s Benefit Plan, benefits are not provided for inpatient hospital confinements for chronic mental illness. An individual is deemed to have chronic mental illness if he/she is confined for more than 90 days over a two-year period, dating from the first day of hospital confinement. Under Q&A #81-6, the limit of “90 days over a two year period” is interpreted as the cumulative number of days of inpatient hospital care for all mental illness diagnoses, without regard to each acute episode.

The information submitted to the Trustees indicates that the Employee’s spouse was confined in a hospital for mental illness for more than 90 days during the two-year period following her first day of confinement in May 1978. Therefore, the spouse would be deemed to have chronic mental illness, for which no benefits are provided under the Employer’s Benefit Plan.

The Employee argues, nevertheless, that days on which the spouse was confined prior to the effective date of the 1981 Employer’s Benefit Plan should not be counted in determining eligibility for benefits for the treatment of mental illness under the 1981 Employer’s Benefit Plan. Under the language of the Plan, however, the factor which is determinative as to whether such benefits will be provided is whether the individual’s mental illness is acute or chronic. If the individual has been confined for more than 90 days over a two-year period, even if that period began prior to the effective date of the Plan, he/she is deemed to have a chronic mental problem for which the Plan does not provide inpatient hospital benefits.

Opinion of the Trustees

The Trustees are of the opinion that the Employer is not responsible for providing benefits for the periods from July 1, 1981 through July 22, 1981 and August 31, 1981 through September 30, 1981.