______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-229 – December 10, 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 coverage for alcoholism and drug rehabilitation services under the terms of the Employer Benefit Plan.
Background Facts
The Employee was admitted as in inpatient to a substance abuse center for treatment of alcoholism. The Employee chose this method of treatment following his suspension pending discharge by the Employer for unauthorized absenteeism. A “last chance agreement” was signed in which the Employee agreed to obtain treatment for his alcoholism and the Employer agreed to reinstate the Employee upon successful completion of the treatment. Concurrent with the signing of the “last chance agreement”, an Employer representative informed the Employee that the Employer Benefit Plan would cover seven (7) days of inpatient treatment for alcoholism. There is no evidence to indicate, nor has the Employee alleged, that there was any promise made to cover any inpatient treatment beyond seven (7) days.
After the Employee completed a 29-day inpatient stay, the substance abuse center billed the Employer’s insurance carrier for 29 days of inpatient care. The carrier paid benefits for seven (7) days, based upon instructions from the Employer to authorize such payment because of extenuating circumstances, but denied payment for the remaining 22 days.
Dispute
Is the Employer responsible for payment of the charges for the remaining 22 days of the Employee’s inpatient hospitalization for alcohol detoxification and treatment?
Position of the Parties
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Position of the Employee: The Employer is responsible for the cost of the remaining 22 days of the inpatient stay because all requirements of the Employer Benefit Plan were met. In addition, under New Mexico state law, health insurers are required to provide alcohol dependency coverage consisting of at least thirty (30) days treatment in an alcohol dependency treatment center.
Position of the Employer: The Employer is not responsible for payment for the cost of the remaining 22 days of the Employee’s inpatient treatment because the Employer Benefit Plan limits the provision of health benefits for inpatient treatment to a maximum of seven (7) calendar days of emergency detoxification. After the first seven (7) days, benefits are provided only for outpatient services, such as alcoholism or drug rehabilitation programs, when medically necessary. The New Mexico state law cited by the Employee is not relevant because it requires only that health insurers offer alcohol dependency coverage to purchasers of group health insurance; it does not require such purchasers to provide the coverage.
Pertinent Provisions Article III. A. (1) (f) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(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 inpatient hospital 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 this 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.
Article III. A. (7) (f) of the Employer Benefit Plan states: (7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addiction Benefits are provided for:
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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 necessary 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.
- Alcoholism and drug rehabilitation programs not approved by Medicare.
New Mexico law 59-18-24 states in part: 59-18-24. Alcohol Dependency Coverage
Each insurer that delivers or issues for delivery in this state a group health insurance policy shall offer and make available benefits for the necessary care and treatment of alcohol dependency. Such benefits shall….provide no less than thirty (30) days necessary care and treatment center….such offer of benefits shall be subject to the right of the group health insurance holder to reject the coverage.
Discussion
Article III. A. (1) (f) of the Employer Benefit Plan provides inpatient benefits for emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of seven calendar days per admission. If treatment of a different medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan. In addition, Article Ill. A. (7) (f) of the Employer Benefit Plan provides outpatient benefits for treatment of alcoholism or drug abuse.
While New Mexico state law does require health insurers to offer alcohol dependency coverage to purchasers of group health insurance, it does not require such purchasers to select the coverage and provide it to the enrollees in their group health plans.
The Employee was admitted as an inpatient to a substance abuse center for twenty-nine (29) days for treatment for alcohol abuse. The Employer agreed to pay for the first seven (7) days of treatment but is not responsible for the remaining 22 days of treatment because there is no
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evidence that the Employee required inpatient care and treatment of any other medical or mental conditions for which benefits may be provided under other provisions of the Plan. Further, because the employee received inpatient (rather than outpatient) treatment for substance abuse, the employer is not responsible for paying benefits for this treatment under Article III A.(7)(f).
Opinion of the Trustees
The Employer is not responsible for paying benefits for the remaining twenty-two (22) days for inpatient alcohol abuse treatment.