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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-611 – March 29, 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 the provision of health benefits coverage for inpatient hospitalization for an Employee’s spouse under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was hospitalized November 29, 1987 through December 10, 1987 for medical problems related to an attempted suicide by drug overdose. Her physician states that she had been receiving psychiatric care for months prior to this for a manic depressive disorder and that her suicide attempt was a complication of her illness.
The Employer denied the provision of health benefits coverage for the Employee’s spouse’s hospitalization because her injury was self-inflicted and, as such, is not a condition for which benefits are specifically provided under the Employer Benefit Plan.
Dispute
Is the Employer responsible for providing health benefits coverage for the Employee’s spouse’s hospitalization related to her attempted suicide?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing health benefits coverage for the Employee’s spouse’s hospitalization for her drug overdose because the services were necessary for the treatment of an illness.
Opinion of Trustees Resolution of Dispute Case No. 84-611 Page 2
Position of the Employer: The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s hospitalization for her drug overdose because treatment for self-inflicted injuries is not a service for which benefits are specifically provided under 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.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that benefits are provided for services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. Although the Employer claims that health benefits coverage for the treatment of self-inflicted injuries is not specifically provided by the Plan, the provisions of the Plan make no distinctions concerning the cause of an illness or injury. The Employer is responsible for providing health benefits coverage for the Employee’s spouse’s hospitalization, consistent with the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse’s hospitalization, consistent with the terms of the Employer Benefit Plan.