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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-540 – February 9, 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 was admitted, to different hospitals, on March 29, 1986 and on June 9, 1986, with lumbar disc displacement and ankylosing spondylitis (rheumatoid arthritis of the spine). The Employee’s physician states that on both admissions the Employee was suffering from situational anxiety related to his diagnosis of acute ankylosing spondylitis and that he was admitted to a private room for both hospitalizations in an effort to facilitate a rapid recovery. The Employer paid for the room charges in both instances at the semi private rate. The Employee stated the full charges for a private room during both hospitalizations should be covered benefits because his physician felt his condition required that he be isolated for his own health or for that of others.
The Employer denied payment of health benefits for a private room for both hospitalizations because there was no documentation establishing that the Employee’s condition required him to be isolated for his own health or for that of others.
The Employer also contends that the prescription of a private room by the Employee’s physician does not mean that it was medically reasonable or necessary or that it is covered under the Plan.
Dispute
Is the Employer responsible for paying benefits for a private room during the Employee’s hospital confinement?
Opinion of Trustees Resolution of Dispute Case No. 84-540
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Positions of the Parties
Position of the Employee: The Employer is responsible for paying the full private room charges because the Employee’s physician recommended a private room.
Position of the Employer: The Employer is not responsible for paying the full private room charges because the Employee’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. (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 semiprivate 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 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.
Although the Employee’s physician ordered a private room in an effort to facilitate a rapid recovery, the doctor does not state that a private room was medically necessary. 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. Inasmuch as the information provided by the Employee and his physician does not establish that the
Opinion of Trustees Resolution of Dispute Case No. 84-540
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Employee required isolation for his 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 hospitalization.