OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
81-323 – November 28, 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 (“UMWA”) 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 coverage of anesthesia services provided to the Employee under the terms of the Employer’s Benefit Plan and hereby render their opinion on the matter.
The Employee became ill and was admitted to the hospital on January 30, 1983. The following day he underwent an appendectomy. The anesthesia services relative to the surgical procedure were provided by an anesthesiologist who is an employee of the hospital. The Employer has denied coverage of the anesthesia services resulting from the Employee’s surgery.
Is the Employer responsible for payment of charges for anesthesia services provided to the Employee?
Positions of the Parties
Employee’s Position; The Employee maintains that the charges for the anesthesia services should be covered because surgery was performed on an urgent basis and because he was not given a choice in determining who his anesthesiologist would be. Furthermore, he contends that he was not provided an explanation as to whether the anesthesiologists work inside or outside of the hospital nor had he been provided with instructions regarding this problem.
Case No. 81-323 Page 2
Employer’s Position: The Employer maintains that the charges for the anesthesia services provided to the Employee are not covered since the anesthesia was administered by an employee of the hospital.
Article III. A. (1) sets forth coverage for services provided by a hospital.
Article III. A.(1)(a) lists the following specific services.
- — operating, recovery, and other treatment rooms
- — laboratory tests and X-rays
- — diagnostic or therapy items and services
- — drugs and medications (including take home drugs which are limited to a 30-day supply)
- — radiation therapy
- — chemotherapy
- — physical therapy
- — anesthesia services
- — oxygen and its administration
- — intravenous injections and solutions
- — administration of blood and blood plasma
- — blood, if it cannot be replaced by or on behalf of the beneficiary.”
Article III. A. (3) sets forth coverage for Physicians’ Services and other Primary Care. Paragraph (d) is as follows:
(d) Anesthesia Services
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.
Case No. 81-323 Page 3
Article III. A. (1) (a) includes anesthesia services provided by the hospital as a covered benefit. Article III. A. (3) provides benefits for physicians’ services and other primary care. Letter (d) under that heading provides benefits for anesthesia services.
The disputed anesthesia charge of $303.67 was billed as an inpatient hospital charge by the North Alabama Hospital. This charge was as a single line item on an itemized bill for the Employee’s hospitalization. It is particularly important to note that this is an inpatient hospital facility charge rather than a billing for professional services. Therefore, the provisions of Article III. A. (1) (a) are applicable.
Were this an anesthesiologist billing for professional services, the provisions of Article III. A. (3) (d) would be applicable in determining whether or not his services would be considered a covered benefit.
Because the hospital billed for these services, the anesthesia charge resulting from the Employee’s surgery is a covered benefit.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is responsible for the payment of charges for the anesthesia services provided to the Employee during his hospitalization at the North Alabama Hospital on January 31, 1983.