OPINION OF TRUSTEES
ROD Case No: 84-718 – September 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 alcoholism and drug rehabilitation services under the terms of the Employer Benefit Plan.
The Employee was hospitalized with a diagnosis of alcohol and drug dependency from September 18, 1987 until October 16, 1987. The Employer provided benefits for the first 7 days of the Employee’s hospitalization, but denied benefits for the remainder of the stay, stating that benefits for emergency detoxification or treatment for drug and alcohol abuse on an inpatient basis are limited to 7 calendar days under the Employer Benefit Plan. In a letter dated March l, 1990, the medical director of the hospital’s substance abuse services stated that the Employee required intensive individual and group therapy beyond the normal detoxification period to deal with underlying issues that contributed to his substance abuse.
Is the Employer required to provide benefits for more than the first 7 days of the Employee’s inpatient treatment for alcohol and drug dependency?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s inpatient treatment because the treating physician determined that an extended stay was medically necessary for treatment of the Employee’s alcohol and drug dependency.
Position of the Employer: The Employer is not required to provide benefits for more than the first 7 days of the Employee’s treatment because benefits for inpatient treatment of alcohol and drug abuse are limited to 7 calendar days per admission under Article III. A. (1)(f) of the Employer Benefit Plan, and there is no indication that treatment of any other medical or mental condition was provided.
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.
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. (1)(e) of the Employer Benefit Plan provides inpatient hospitalization benefits for a Beneficiary who is confined for treatment of mental illness. In addition, Article Ill. A. (7)(f) of the Employer Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
The Employee was hospitalized from September 18, 1987 until October 16, 1987 for treatment of alcohol and drug dependency. The Employer paid the charges for the first 7 days of treatment but denied payment for the remainder of the hospitalization. The hospital records provided in this case indicate that the Employee was treated in the hospital’s 28-day ARU (alcohol rehabilitation unit) program for alcohol and drug dependency. A Funds’ medical consultant has reviewed this file and has advised that the medical documentation indicates that the patient’s entire admission was for detoxification and treatment for substance abuse. The consultant has advised that the documentation does not establish that the patient was treated for other medical or mental conditions during this admission. Inasmuch as the Employee received inpatient hospital care for the treatment of alcohol and drug dependency, the Employer is not responsible for providing benefits beyond those paid for the first 7 days of the Employee’s hospitalization, consistent with the terms of Article III. A. (1)(f) of the Plan. Furthermore, because the treatment was rendered in an inpatient (rather than outpatient) program, the Employer is not responsible for providing health benefits under Article III. A. (7)(f).
Opinion of the Trustees
The Employer is not required to provide any additional benefits for the Employee’s hospitalization for treatment of alcohol and drug dependency.