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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-717 – July 25, 1990
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 treatment for alcoholism under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was hospitalized from March 24, 1987 to April 7, 1987 with a diagnosis of acute and chronic alcoholism, mild depression and alcoholic gastritis. A psychiatrist, who reviewed the medical records of the Employee’s spouse’s hospitalization at her request, stated that he felt alcohol detoxification took place for approximately 7 days, after which she was involved for seven more days in the alcohol rehabilitation program and was discharged on a tranquilizer and an antidepressant. Following discharge, the patient was treated on an outpatient basis with lithium carbonate for a bipolar affective disorder.
The Employer provided coverage for the first 7 days of the Employee’s spouse’s hospitalization but denied coverage for the last 7 days of her stay.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s hospitalization for alcoholism for more than 7 days?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for more than 7 days of the Employee’s spouse’s hospitalization for alcoholism because extended hospitalization was medically necessary for treatment of her manic-depressive illness (a bipolar affective disorder).
Position of the Employer: The Employer is not required to provide benefits for more than the first 7 days of the Employee’s spouse’s hospitalization because there is no evidence that the Employee’s spouse was being treated for any condition other than alcohol detoxification and rehabilitation. Benefits for inpatient treatment for alcoholism or drug abuse are limited to 7 days per hospital admission.
Pertinent Provisions
Article III. A. (I)(e) and (f) of the Employer Benefit Plan state:
(1) Inpatient Hospital Benefits
(e) Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. When medically necessary, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period, (dating from the first day of hospital confinement, even if the first day of confinement occurred during a prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide 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:
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 required by a physician,
Benefits are not provided for:
1. Encounter and self-improvement group therapy.
2. Custodial care related to mental retardation and other mental deficiencies.
3. School related behavioral problems.
4. Services by private teachers.
5. 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.
6. Alcoholism and drug rehabilitation programs not approved by Medicare.
Discussion
Article III. A. (I)(f) of the Employer Benefit Plan provides inpatient hospitalization benefits for a Beneficiary who requires emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of 7 calendar days per admission. If treatment of a medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan. Article III. A. (I)(e) of the Employer Benefit Plan provides inpatient hospitalization benefits for a Beneficiary who is confined for treatment of mental illness. In addition, Article III. A. (7)(f) of the Employer Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
The Employee contends that an extended period of hospitalization was medically necessary to treat the major bipolar affective disorder which was associated with the Employee’s spouse’s acute and chronic alcoholism. A Funds’ medical consultant has reviewed the information submitted in this file and has advised that the documentation indicates that the patient’s admission was for alcoholic detoxification and rehabilitation and that she was discharged on a tranquilizer and antidepressant. As noted by the medical consultant, the patient was treated on an outpatient basis following discharge, for a bipolar affective disorder. The medical consultant is of the opinion that the medical documentation provided in this case does not establish that inpatient hospitalization was medically necessary for the treatment of an associated psychiatric illness following the 7-day detoxification period covered by the Employer. Inasmuch as the Employee’s spouse received inpatient hospital care for alcoholic detoxification and rehabilitation, the Employer is not required to provide inpatient hospitalization benefits beyond those paid for the first 7 seven days of the Employee’s spouse’s hospitalization, consistent with the terms of Article III. A. (I)(f) of the Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for more than 7 days of the Employee’s spouse’s hospitalization for alcoholism.