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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-485 – August 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 payment for air ambulance charges and hereby render their opinion on the matter.
Background Facts
Because the Employee’s pregnant spouse had an Rh sensitivity there was a known risk to the baby. She was therefore referred to the High Risk Obstetrics Clinic at the University of Colorado Health Science Center, located approxImately 250 miles from her home. The Employee’s son was born prematurely at this facility on March 15, 1982. Following his birth, he received neonatal care in the Intensive Care Nursery of the University of Colorado Health Science Center.
By March 23, 1982, a medical decision was made that the child no longer required the services of the University Intensive Care Nursery. Although the child required further care because of its prematurity, it was determined that he could be transferred to and cared for at the St. Mary’s Hospital in Grand Junction, Colorado, which was closer to his parents’ home. This transfer was carried out via helicopter (air ambulance).
The child’s attending physician in Grand Junction felt that the transfer was necessary so that the child’s care would include intense involvement with his own parents. Because the child was in 28% oxygen, in an isolette, and on a cardiac monitor, this physician felt the transfer should be carried out by air ambulance. In addition, the child’s attending pediatrician at the University Intensive Care Nursery noted that the indications for this transfer were (1) to enhance parental attachment (since the child would be closer to home the parents would be able to visit more frequently) and (2) to enable the parents to learn to care for the child prior to his discharge.
The Employer has denied payment of the charges resulting from the Employee’s child’s air ambulance transfer.
Is the Employer responsible for payment of the air ambulance charges incurred in transferring the Employee’s son from the University of Colorado Health Science Center to St. Mary’s Hospital in Grand Junction, Colorado?
Positions of the Parties
Employee’s Position: The Employee and his spouse maintain that since their child 5 doctors felt that it was in his best interest to be transferred to a hospital near his home for subsequent neonatal care and because the use of an air ambulance was medically necessary due to the child’s medical condition, the Employer is responsible for providing payment for this transfer.
Employer’s Position: The Employer bases the denial of coverage on Article III A. (7) (e) of the Employer’s Benefit Plan which stipulates that benefits for ambulance transportatIon are provided to or from a hospital only when considered medically necessary by a physician. The Employer has expressed the opinion that the transfer of the Employee’s son to the St. Mary’s Hospital was not medically necessary since the additional non-intensive care required due to the child’s prematurity was available at the facility where the child was born. The Employer maintains, therefore, that the air ambulance charges were properly denied.
Pertinent Provisions
Article III. A. (7)(e) of the Employer’s Benefit Plan states in relevant part:
Benefits are provided for ambulance transportation to or from a hospital, clinic, medical center, physician’s office, or skilled nursing care facility, when considered medically necessary by a physician.
Discussion
According to Article III. A. (7)(e) of the Employer’s Benefit Plan, benefits are provided for ambulance transportation only when such transportation is considered medically necessary by a physician. The Employee’s son was transferred to St. Mary’s Hospital in Grand Junction in order to enhance parental attachment and to permit the parents to learn to care for the child. Because the inpatient services that the child required subsequent to his discharge from the Intensive Care Nursery were available at the University of Colorado Health Science Center, the transfer was not medically necessary.
Opinion of the Trustees
The Employer is not responsible for providing payment of the air ambulance charges resulting from the transfer of the Employee’s son from the University of Colorado Health Science Center in Denver, Colorado to the St. Mary’s Hospital in Grand Junction, Colorado. Trustee Combs disse