Opinion of Trustees
Resolution of Dispute
Case No. 88-127
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
88-127 – February 28, 1991
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 benefits for inpatient treatment for drug and alcohol dependency under the terms of the Employer Benefit Plan.
The Employee was treated in a hospital-based inpatient chemical dependency unit from March 9, 1988 to April 6, 1988. The hospital records indicate that the Employee’s principal diagnosis was alcohol, cocaine and minor tranquilizer dependence. A history of narcotic and marijuana abuse was also noted. The Employee’s treatment plan included routine detoxification, participation in individual, group and family counseling, alcohol and substance abuse education and an introduction to Alcoholics Anonymous meetings.
The Employer provided coverage for the first seven days of the Employee’s hospitalization including charges for room and board, drugs, laboratory and physician visits. The Employer has denied the Employee’s request for additional benefits.
Is the Employer required to provide additional benefits under the Employer Benefit Plan for the Employee’s inpatient treatment for drug and alcohol dependency?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s entire period of hospitalization because a representative of the Employer’s insurance carrier told a hospital representative at the time of admission that coverage would be provided for 30 days,
Opinion of Trustees Resolution of Dispute Case No. 88-127
and because other Employees of the Respondent have received coverage for their entire periods of hospitalization for similar problems.
Position of the Employer: The Employer is not required to provide additional benefits for the Employee’s inpatient treatment for drug and alcohol dependency because the Employer Benefit Plan limits coverage for such treatment to seven calendar days per admission, and the medical records do not indicate that the Employee received treatment for any medical or mental condition for which benefits would be provided under other Plan provisions after the covered seven-day detoxification period.
Pertinent Provisions Article III. A. (1)(f) of the Employer Benefit Plan provides:
(1) 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 provides in pertinent part: (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.
Opinion of Trustees Resolution of Dispute Case No. 88-127
Article III. A. (1)(f) of the Employer Benefit Plan provides benefits for inpatient treatment of alcoholism and drug abuse when a beneficiary requires emergency detoxification or emergency treatment for drug abuse for a maximum of 7 calendar days per inpatient hospital admission. If inpatient treatment of a medical or mental condition is necessary following detoxification, benefits may be payable under other provisions of the Plan. In addition, Article III. A. (7)(f) of the Employer Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
The Employee in this case was hospitalized from March 9, 1988 to April 6, 1988 for treatment of alcohol and drug dependency. The records provided indicate that the Employee underwent routine detoxification with no medical complications, participated in individual, group and family counseling, and received alcohol and substance abuse education. There is no indication in the record nor does the Employee allege that inpatient treatment for other medical or mental conditions was required during this admission. Inasmuch as the Employee received inpatient hospital care for drug and alcohol dependency, and the Employer has provided benefits for the first seven calendar days of the admission, the Employer is not required to provide additional benefits, consistent with the terms of Article III. A. (1)(f) of the Plan.
Although the Employee has alleged that, at the time of his admission, a hospital representative was told that his insurance would cover hospitalization for up to 30 days, there is no indication that either the Employee or the provider was misled regarding the coverage requirements and limitations of Article III. A. (1)(f) of the Plan. Finally, the fact that the Employer may have provided benefits in other situations for periods of hospitalization beyond the 7-day period covered under Article III. A.(1)(f) does not make the services in question in this case covered benefits under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide additional benefits for the Employee’s inpatient treatment for alcohol and drug dependency from March 9, 1988 to April 6, 1988.