OPINION OF THE TRUSTEES
ROD Case No: 84-113 February 24, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee;, William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 for travel expenses under the terms of the Employer Benefit Plan.
The Employee’s spouse was referred by her attending physician to the Duke University Medical Center for evaluation and treatment. Prior to obtaining this evaluation, the Employee contacted his Employer to advise him of this referral and to obtain the necessary authorization for reimbursement of the travel expenses attendant to seeking the medical care recommended by the Employee’s spouse’s attending physician. According to the Employee, the Employer authorized reimbursement of the travel expenses and advised him to document mileage and expenses. The Employee complied with these instructions. Subsequent to submitting his expenses related to obtaining the out-of-area medical care, the Employee’s claim was denied.
The Employer contends that its denial of these charges was correct since in its opinion the Duke University Medical Center was not the closest facility offering the specific services needed and because it contends that prior approval had not been granted.
The Employee’s spouse’s attending physician has stated that in his opinion, the Duke University Medical Center was the most appropriate place to send the Employee’s spouse.
Is the Employer responsible for providing payment for travel expenses for the Employee and his spouse?
Position of the Parties
Position of the Employee: The Employee contends that he obtained prior authorization for reimbursement of the travel expenses relative to his spouse’s out-of-area medical care and therefore maintains that the expenses attendant to receiving this care are covered under the terms of the Employer Benefit Plan.
Position of the Employer: The Employer maintains that the Employee did not satisfy the conditions for travel reimbursement as established in Article III. A. (7) (e) of the Employer Benefit Plan.
Article III. A. (7) (e) of the Employer Benefit Plan states:
(e) Ambulance and other transportation
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. With prior approval from the Plan Administrator, benefits will also be provided for other transportation subject to the following conditions:
1. If the needed medical care is not available near the Beneficiary’s home and the Beneficiary must be taken to an out of area medical center.
2. If the Beneficiary requires frequent transportation between the Beneficiary’s home and a hospital or clinic for such types of treatment as radiation or physical therapy or other special treatment which would otherwise require hospitalization, benefits will be provided for such transportation only when the Beneficiary cannot receive the needed care without such transportation.
3. If the Beneficiary requires an escort during transportation, the attending physician must submit satisfactory evidence as to why the Beneficiary needs an escort.
Article III A. (7) (e) of the Employer Benefit Plan provides benefits for transportation to an out-of-area medical center for medically necessary care which is not available near the Beneficiary’s home. Such transportation must be authorized by the Plan Administrator.
In the opinion of the Employee’s spouse’s attending physician, the necessary medical care the patient required was not available locally; therefore, he referred her to the Duke University Medical Center. He further indicates that although this facility may not have been the closest medical facility to the patient’s home, it was the closest appropriate center for the patient’s needs. Furthermore, the physician has stated that the patient’s attacks of severe abdominal pain made it unwise for her to drive alone, and therefore an escort was necessary.
The Employee attempted to obtain from the Employer prior authorization of benefits for transportation, and complied with the Employer’s instructions to document travel expenses. Because the Employee took measures to obtain prior approval which was not denied, and because there is no evidence that the needed medical care was available close to the Employee’s home, the Trustees find that the requirements of Article III A. (7) (e) of the Employer Benefit Plan have been satisfied.
Opinion of the Trustees
The Employer is responsible for payment of the travel expenses relative to the Employee’s spouse’s out-of-area care at the Duke University Medical Center.