OPINION OF TRUSTEES
ROD Case No: 81-391 – February 27, 1984
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 alcoholism and drug rehabilitation services and hereby render their opinion on the matter.
The Employee was eligible for health benefits under the Employer’s Benefits Plan at the time the services in dispute were rendered. Immediately following a seven-day hospitalization, the Employee was admitted to an inpatient rehabilitation facility for the treatment of his drug and alcohol addiction. The Employer has denied payment for the charges resulting from this admission.
Question or Dispute
Is the Employer responsible for payment of the charges incurred by the Employee as a result of his inpatient admission to a rehabilitation facility for the treatment of his drug and alcohol addiction?
Positions of the Parties
Position of the Employee: The Employee’s Representative maintains that, since the Employee was referred to the rehabilitation facility by his attending physician, the expenses for this service fall within the guidelines of the Employer’s Benefit Plan and should therefore be paid by the Employer.
Position of the Employer: The Employer has referenced in support of its denial the Plan provision which requires that an advance determination be performed by the rehabilitation team to determine that the beneficiary is a good candidate for rehabilitation. In addition, the Employer notes that the Plan requires that if free care sources are available, they must be utilized.
According to the Employer, the advance determination supports a position that the Employee was not a good candidate for rehabilitation and that the Employee refused to accept the services of the free care sources available to him. The Employer therefore refuses to pay the charges incurred by the Employee for his treatment at the rehabilitation center.
Article III A. (1) (a) (f) and (i) of the Employer’s Benefit Plan state:
A. Health Benefits
(1) Inpatient Hospital Benefits
(a) Semi-private room
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations…
(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 in-patient admission.
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 the Plan and are subject to any requirements or limitations in such provisions.
See paragraph (7)(f) for information concerning other services related to treatment of alcoholism and drug abuse.
Accredited Hospital is a hospital which is operated primarily for the purpose of rendering inpatient therapy for the several classifications of medical and surgical cases and which is approved by the Joint Commission of Accreditation of Hospitals or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.
Article III A. (7) (f) of the Employer’s Benefit Plan states:
(f) Outpatient Mental Health, Alcoholism and Drug Addition
Benefits are provided for:
Psychotherapy, psychological testing, counseling, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically required by a physician.
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other medical deficiencies.
3. School related behavioral problems.
4. Services by private teachers.
5. Alcoholism and drug rehabilitation if an advance determination has not been made by the rehabilitation team that the Beneficiary is a good candidate for rehabilitation.
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
According to a bill the Employee submitted to the Employer for consideration, the services in dispute are the result of an inpatient confinement. The Employer’s Benefit Plan provides inpatient benefits for the treatment of alcoholism and drug abuse only for emergency detoxification or treatment and for a maximum of seven calendar days per admission. Furthermore, inpatient benefits are only covered for treatment in an accredited hospital. According to the Plan, an accredited hospital is a hospital operated primarily for the purpose of rendering inpatient therapy for the several classifications of medical and surgical cases. In addition, the Plan requires that a hospital be approved by the Joint Commission on Accreditation of Hospitals (“JCAH”) or by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust. There is no indication that the Employer required emergency detoxification upon admission to the rehabilitation facility. ln addition, this facility is not a JCAH accredited hospital nor has it been approved as a hospital by the Trustees of the 1950 Benefit Trust.
An issue raised by the parties to this dispute is whether the Employee received an advance determination that he was a good candidate for rehabilitation. Based on the information provided, the Trustees are unable to determine that the Employee underwent an advance determination by the rehabilitation team. The Trustees do note that the information provided by the Employee’s attending physician and psychologist is insufficient to establish that he was a “good candidate for rehabilitation.” In light of the foregoing discussion, however, it is immaterial whether or not an advance determination was made.
Therefore, the Employer is not responsible for the provision of benefits for the Employee’s inpatient rehabilitation treatment.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment of the charges resulting from the Employee’s inpatient drug and alcoholism rehabilitation treatment.