OPINION OF TRUSTEES
Respondent: Employer (Insurance Company)
ROD Case No: 81-293 September 27, 1983
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 level of health benefits for anesthesia charges and hereby render their opinion on the matter.
The Complainant is an active Employee eligible for health benefits under the Employer’s Plan. The Employer’s dependent spouse was admitted to the hospital for a D&C on September 12, 1981. Anesthesia was administered by the operating surgeon or his assistant during the procedure.
Question or Dispute
The Employee filed a claim for coverage of the physician’s charges, including charges for anesthesia services. The Employer has denied payment for the anesthesia services.
Position of the Parties
Claimant’s Position: The Employer is responsible for payment of the charges for anesthesia services including the interest charges accrued to date.
Employer’s Position: The Employer is not responsible for payment of the claim for anesthesia services nor the interest charges related to that charge since the anesthesia services are not covered when administered by the operating physician according to Article III, Section A (3)(d) and Article III, Section A (11)(a)(18) of the Benefit Plan,
Article III Section A (3)(d) of the Employer Plan provides as follows:
Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, who is not an employee of, nor compensated by, a hospital, laboratory or other institution.
Article III, Section A (11)(18) of the Employer Plan provides as follows:
In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
Finance charges in connection with a medical bill.
The anesthesia services in question were administered by the operating surgeon or his assistant. The governing provisions of the Plan exclude coverage for anesthesia services when administered by the operating surgeon or his assistant as well as the payment of finance charges.
Opinion of Trustees
The Trustees are of the opinion that the Employer is not responsible for payment of the anesthesia service-charges nor the attendant interest charges incurred by the Employee’s spouse aa a result of her surgical procedure.