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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-349 – April 7, 1987

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 payment of benefits for a private hospital room under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was hospitalized for four days in July 1986, during which time she occupied a private hospital room after undergoing a left modified radical mastectomy. The Employee’s spouse reports that her surgeon stated a private room was medically necessary after her surgery. A letter from the surgeon indicates that the Employee’s spouse requested a private room and that he thought a private room would be helpful because the Employee’s spouse was in “severe emotional distress” after the surgery and would benefit from having a relative stay with her overnight in the private room.

The Employer paid benefits up to the hospital’s charges for semi-private room accommodations for the four days but has denied room charges in excess of the semi-private room rate.

Dispute

Is the Employer responsible for paying benefits for a private room during the Employee’s spouse’s hospital confinement?

Positions of the Parties

Position of the Employee: The Employer is responsible for the private room charges because the Employee’s spouse’s doctor recommended a private room.

Position of the Employer: The Employer is not responsible for private room charges because the Employee’s spouse’s condition does not meet the requirements for a private room under Article III.A.(1)(c) of the Employer Benefit Plan.

Pertinent Provisions

Article III. A. (l)(c) of the Employer Benefit Plan states:

(c) Private Room

For confinement in a private room, benefits will be provided for the hospital’s most common charge for semi-private room accommodations and the Beneficiary shall be responsible for any excess over such charge except that private room rates will be paid when (i) the Beneficiary’s condition requires him to be isolated for his own health or that of others, or (ii) the hospital has semi-private or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. Semi-private room rates, not private room rates, will be paid beyond the date a semi-private room first becomes available and the Beneficiary’s condition permits transfer to those accommodations.

Article III. A. (11)(a) 10 of the Employer Benefit Plan states:

(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

10.Charges for private room confinement, except as specifically described in the Plan.
Discussion

Article III.A.(1)(c) of the Employer Benefit Plan provides benefits for a private room when a beneficiary’s condition requires isolation for his/her own health or that of others, or if a beneficiary requires immediate hospitalization and only a private room is available because all semi-private or less expensive accommodations are occupied.

Although the Employee’s spouse reports that the private room was deemed medically necessary by her surgeon, the surgeon states that the Employee’s spouse requested a private room and that he thought it would be very helpful for her recovery, but does not state that a private room was medically necessary.

Since the information provided by the Employee’s spouse and the Employee’s spouse’s surgeon does not establish that her confinement in a private room was due to a condition which required isolation for her own health or that of others, or that a private room was otherwise medically necessary, the Employer is not responsible for payment of the private room charges.

Opinion of the Trustees

The Employer is not responsible for paying benefits for a private room for the Employee’s spouse’s hospitalization.