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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-533 – February 25, 1988
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 from January 29, 1987 to February 13, 1987 for lung surgery. Following the surgery, she was admitted to the intensive care unit and then to a private room. Her surgeon has indicated that he felt a private room was necessary due to the type of surgery performed. He stated that it is standard procedure for a patient to be admitted to a private room after lung surgery.
The Employer has denied payment of the extra charge for a private room because there is no medical evidence establishing that the Employee’s spouse’s condition required her to be isolated for her own health or for that of others, as required under Article III. A. (1)(c) of the Employer Benefit Plan. The Employer paid for the room charges at the semiprivate rate. The Employee contends that the Employer should pay the full charges for a private room because it was deemed medically necessary by the treating physician.
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 paying the full charges for a private room because the Employee’s spouse’s physician ordered a private room.
Position of the Employer: The Employer is not responsible for paying the full charges for a private room 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
The Introduction to Article III of the Employer Benefit Plan states in part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (1)(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 semiprivate 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 semiprivate or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. Semiprivate 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 Plan provides benefits for a private room when a Beneficiary’s condition requires isolation for his own health or that of others, or if a Beneficiary requires immediate hospitalization and only a private room is available because all semiprivate or less expensive accommodations are occupied. The Introduction to Article III of the Employee Benefit Plan stipulates that the fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Although the Employee’s spouse’s physician has stated that the private room was necessary and consistent with standard procedure for postoperative lung surgery patients, no specific medical justification of the Employee’s spouse’s need for a private room has been provided. A Funds’ medical consultant has reviewed the case and advised that there is insufficient medical documentation to establish the medical necessity of a private room for the Employee’s spouse. Inasmuch as the information provided by the Employee and the physician does not establish that the Employee’s spouse 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 payment of the private room charges incurred during the Employee’s spouse’s hospitalization.