______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-067 – September 4, 1985
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; William B. Jordan, 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 the provision of health benefits coverage for inpatient alcoholism and drug rehabilitation services under the terms of the Employer Benefit Plan and hereby render their opinion on the matter.
Background Facts
Following a four day hospitalization for detoxification, 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.
Dispute
Is the Employer responsible for payment of the charges resulting from the care and treatment of the Employee’s drug and alcohol addiction in an inpatient treatment center?
Positions of the Parties
Position of the Employee: The Employee’s Representative maintains that the charges for this service fall within the guidelines of the Employer Benefit Plan and should therefore be paid by the Employer.
Position of the Employer: The Employer notes that the services the Employee received at the treatment center did not constitute emergency detoxification hospital care. Furthermore, these services were provided on an inpatient basis and are not covered under Article III A. (7) (f) of the Employer Benefit Plan since this section applies to out-patient treatment only.
Opinion of Trustees Resolution of Dispute Case No. 84-067 Page 2
Pertinent Provisions
Articles III A. (1) (a), (f) and (i) of the Employer Benefit Plan state:
A. Health Benefits
(1) In-patient Hospital Benefits
(a) Semi-Private room
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an in-patient 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.
(i) General
Accredited Hospital is a hospital which is operated primarily for the purpose of rendering in-patient therapy for the several classifications of medical and surgical cases and which is approved by the Joint Commission on Accreditation of Hospitals or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.
Opinion of Trustees Resolution of Dispute Case No. 84-067 Page 3
Article III A. (7) (f) of the Employer Benefit Plan states:
(f) Out-Patient Mental Health, Alcoholism and Drug Addiction
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:
- Encounter and self-improvement group therapy.
- Custodial care related to mental retardation and other mental deficiencies.
- School related behavioral problems.
- Services by private teachers.
- 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.
5. Alcoholism and drug rehabilitation programs not approved by Medicare.
Discussion
The services disputed in this case are the result of an in-patient confinement. The Employer Benefit Plan provides in-patient 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, in-patient 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 in-patient 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 Employee required emergency detoxification upon admission to the treatment center. In 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.
Opinion of Trustees Resolution of Dispute Case No. 84-067 Page 4
Therefore, the Employer is not responsible for the provision of benefits for the in-patient treatment of the Employee’s drug and alcohol addiction at the treatment center.
Opinion of the Trustees
The Employer is not responsible for payment of the charges resulting from the Employee’s in- patient drug and alcoholism rehabilitation treatment.