March 29, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-173
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 your Request for Advisory Opinion concerning coverage of some of your wife’s treatment services in connection with her hospitalization from October 20, 1981 to November 25, 1981 in the Environmental Control Unit of an Environmental Health Center. The Employer has paid charges for diagnostic x-rays and laboratory tests, but has denied charges for room, board, drugs and medical treatment.
Your wife was hospitalized from October 20, 1981 to November 25, 1981 for diagnostic and treatment servIces for allergy. On August 12, 1981 and September 11, 1981. prior authorization for this treatment was requested from the Plan Administrator. AuthorIzation was delayed because the Plan Administrator requested information for review. After the treatment was rendered, the Employer received the requested information and determined that the treatment was not a covered benefit under the Plan. The Dallas County Medical Society has generally reviewed the type treatment received by your wife and has stated that this treatment is not generally acceptable in the medical profession.
Under Article III. A. (11)(a) 24. of the Employer’s Benefit Plan, benefits are excluded for treatment with new technological medical devices and therapy which is experimental in nature. According to the information available to the Trustees, the treatment received by your wife is still being researched and is considered to be experimental. Therefore, your Employer is not responsible for payment of the denied charges for your wife’s treatment services in the Environmental Control Unit.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
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Paul R. Dean, Trustee