April 29, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-559
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 Request for Resolution of Dispute you submitted on behalf of Mr. Arthur R. Mena concerning benefits coverage for anesthesia services, and hereby render their opinion in this matter.
In this case, Mr. Mena was administered anesthesia to facilitate electroshock therapy as part of the treatment for a psychiatric condition. The insurance carrier, acting under company instructions, denied benefits coverage for the anesthesia services related to this therapy, based on the company’s interpretation of Article III A. (3) (d) of the 1981 Benefit Plan. The company interprets this provision as limiting anesthesia to surgical or obstetrical cases only.
Article III A. (3) (d) of the Benefit Plan states:
(d) Anesthesia Services
Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical and 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.
The Employer considers this language as limiting benefits for anesthesia to cases involving surgery or obstetrics. Because Mr. Mena’s medical condition did not involve surgery and was not related to obstetrical care, it was determined that benefits were not payable for the anesthesia services he required.
The Employer is correct in determining that Mr. Mena’s care did not involve surgery or obstetrical services. The anesthesia he required, however, was provided as part of the treatment for his psychiatric condition by a consulting physician. Article III A. (3) (l) of the Plan provides:
(1) Medical Consultation
Benefits are provided for services rendered, at the request of the physician in charge of the case by a physician who is qualified in a medical specialty necessary in connection with medical treatment required by a Beneficiary.
Mr. Mena’s electroshock therapy was part of treatment for a psychiatric condition for which he is currently under a physician’s care. Because the anesthesia required to effect this treatment was administered by a consulting physician who is a qualified specialist and was necessary in connection with Mr. Mena’s medical treatment, the anesthesiology services Mr. Mena required and received are considered a covered benefit under Article III A. (3) (1) of the Employer Benefit Plan.
The Employer is responsible for the provision of benefits coverage for the anesthesia services administered to Mr. Mena as part of the electroshock therapy he received for the treatment of his mental condition.
Sincerely,
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Joseph P. Connors, Sr., Chairman
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Paul R. Dean, Trustee
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William B. Jordan, Trustee
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William Miller, Trustee
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Donald E. Pierce, Jr., Trustee