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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-028 – November 22, 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 outpatient intravenous antibiotic therapy under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner, who has a history of pneumoconiosis, chronic obstructive pulmonary disease and chronic bronchitis, was diagnosed with aspergillosis, a type of infection, of the left lung. His physician states that hospitalization was not required for the Pensioner to receive the intravenous antibiotic therapy necessary to treat his condition; therefore, the intravenous antibiotic therapy was administered in the outpatient department of a hospital. The Pensioner received two such courses of treatment. The first course consisted of intravenous infusions three times a week for four weeks beginning on November 2, 1987. A second series of treatments was administered three times a week for approximately two weeks beginning on March 2, 1988.
The Employer denied coverage for the outpatient intravenous antibiotic therapy, stating that intravenous administration is not a covered service under the Employer Benefit Plan.
Dispute
Is the Employer responsible for providing benefits for the Pensioner’s intravenous antibiotic therapy administered in the outpatient department of a hospital?
Positions of the Parties
Position of the Pensioner: The Employer is responsible for providing benefits for the intravenous antibiotic therapy because it was medically necessary for the treatment of the Pensioner’s illness.
Position of the Employer: The Employer is not responsible for providing benefits for the intravenous antibiotic therapy administered in the outpatient department of a hospital because it is not a covered service under the Employer Benefit Plan.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
Article III – Benefits
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.
Article III. A. (3)(h) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illness or injuries, if provided by a physician.
Discussion
The Introduction to Article III of the Employer Benefit Plan states that covered services are 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. Under Article III. A. (3)(h) of the Employer Benefit Plan, benefits are provided for services rendered by a physician to a Beneficiary in the outpatient department of a hospital for the treatment of illnesses or injuries.
In this case, the Pensioner received intravenous administrations of antibiotics in the outpatient department of a hospital for the treatment of his lung infection. A Funds’ medical consultant has reviewed this case and advised that the outpatient treatment of the Pensioner’s aspergillosis with intravenous injections of antibiotics was medically necessary and rendered at the appropriate level of care, thereby avoiding extended inpatient hospitalization. The antibiotic treatments were ordered and supervised by the patient’s physician. Inasmuch as the Pensioner’s physician provided intravenous injections of antibiotics which were medically necessary for the treatment of the Pensioner’s aspergillosis, such treatment is covered under Article III. A. (3)(h) of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for providing benefits for the Pensioner’s intravenous antibiotic therapy treatments administered in the outpatient department of a hospital.