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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-208 – February 28, 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 benefits for a private room under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was hospitalized from April 27, 1988 to June 8, 1988 and from June 20, 1988 to July 13, 1988, the date of her death, for the treatment of rectal carcinoma. The Employee’s spouse’s physician has stated in a letter dated March 29, 1989, that the Employee’s spouse required a private room during both admissions. He states that she was on an epidural morphine pump program, had evidence of bowel obstruction and myelosuppression (reduction in the bone marrow’s production of blood cells and platelets), and required antibiotics and chemotherapy.

The Employer has denied payment of the extra charge for a private room during both admissions, stating that there is no medical evidence to establish that the Employee’s spouse’s condition required her to be isolated for her own health or for that of others, and there is no indication that a semi-private room was unavailable. The Employer paid for the room charges at the semi-private rate.

Dispute

Is the Employer required to provide benefits for a private room during the Employee’s spouse’s hospital admissions from April 27, 1988 to June 8, 1988 and from June 20, 1988 to July 13, 1988?

Positions of the Parties

Position of the Employee: The Employer is required to pay the full charges for a private room because the Employee’s spouse’s physician has stated that a private room was medically necessary.

Position of the Employer: The Employer is not required to pay the full charges for a private room because the Employee’s spouse’s condition does not meet the requirements for a private room under Article III. A. (1)(c) of the Employer Benefit Plan.

Pertinent Provisions

The Introduction to Article III of the Employer Benefit Plan states in part:

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. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan….

Article III. A. (1)(c) of the Employer Benefit Plan states:

(1) Inpatient Hospital Benefits

(c) Private Room

For confinement in a private room, benefits will be provided for the hospital’s most common charge for semi-private room accommodations and the Beneficiary shall be responsible for any excess over such charge except that private room rates will be paid when (i) the Beneficiary’s condition requires him to be isolated for his own health or that of others, or (ii) the hospital has semi-private or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. Semi-private room rates, not private room rates, will be paid beyond the date a semi-private room first becomes available and the Beneficiary’s condition permits transfer to those accommodations.

Article III. A. (11)(a) 10. of the Employer Benefit Plan states:

(11) General Exclusions

(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

10. Charges for private room confinement, except as specifically described in the Plan.

Discussion

The Introduction to Article III of the Employer Benefit Plan stipulates that 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. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under the Plan. Article III. A. (1)(c) of the Employer Benefit Plan provides benefits for a private room when a Beneficiary’s condition requires isolation for his own health or that of others, or when a Beneficiary requires immediate hospitalization and all semi-private or less expensive accommodations are occupied.

Although the Employee’s spouse’s physician has stated that the Employee’s spouse required a private room, no specific medical justification of the Employee’s spouse’s need for a private room has been provided. A Funds’ medical consultant has reviewed this case, including the letter from the Employee’s spouse’s physician. The consultant advises that there is insufficient medical documentation to establish that the Employee’s spouse required isolation in a private room for her own health or that of others, or that a private room was otherwise medically necessary during either of the two hospitalizations in question. Because the medical necessity of a private room for the Employee’s spouse has not been established, the Employer is not required to pay the private room charges incurred during the Employee’s spouse’s hospitalizations from April 27, 1988 to June 8, 1988 and from June 20, 1988 to July 31, 1988.

Opinion of the Trustees

The Employer is not required to pay the private room charges incurred during the Employee’s spouse’s hospitalizations from April 27, 1988 to June 8, 1988 and from June 20, 1988 to July 31, 1988.