In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-493 – April 14, 1992

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 in hospital physician visits under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse was hospitalized from May 24 through June 24, 1991. During her hospitalization numerous doctors were involved in her treatment, and those physicians billed for their services independently. The Employer required a $7.50 co-payment for each physician visit, up to the plan maximum of $150. This was reached on June 14, 1991.

The Employee contends that the co-payments should not have `been applied to each physician visit during the hospitalization.


Was the Employer correct in applying a $7.50 co-payment for each physician’s inpatient visit?

Positions of the Parties

Position of the Employee: The co-payment applies to office visits, it should not be applied to hospital visits.

Position of the Employer: The Employer was correct In the application of a $7.50 co-payment for each inpatient physician visit, up to the $150 plan year maximum, as stated in Article III. A (8) of the Employer Benefit Plan.

Pertinent Provisions

Article III. A (3)(g), (I) and (m) of the Employer Benefit Plan states:

(g) Inhospital Physicians’ Visits

If a Beneficiary is confined as an inpatient in a hospital because of an illness or injury, benefits are provided for in hospital visits by the physician in charge of the case. Such benefits will also be provided concurrently with benefits for surgical, obstetrical and radiation therapy services when the Beneficiary has a separate and complicated condition, the treatment of which requires skills not possessed by the physician who is rendering the surgical, obstetrical or radiation therapy services.


(1) Medical Consultation

Benefits are provided for services rendered, at the request of the attending physician in charge of the case, by a physician who is qualified in a medical specialty necessary in connection with medical treatment required by a Beneficiary.

(m) Specialist Care

Benefits will be provided for treatment prescribed or administered by a specialist if the treatment is for illness or injury which falls within the specialist’s area of medical competence.

Article III A. (8) of the Employer Benefit Plan state in pertinent part:

(8) Co-Payments

Certain benefits provided in this Plan shall be subject to the co-payments set forth below and such co-payments shall be the responsibility of the Beneficiary….

Co-Payments for covered Health Benefits are established as follows:

Benefit Co-Payment

(a) Physician services as an out Working Group — $7.50 per
patient as set forth in Section A visit up to a maximum of $150
(2) and physician visits in con- per 12-month period(*) per
nection with the benefits set family.
forth in Section A(3), paragraph Non-working Group — $5 per
(c) but only for pre- and post- visit up to a maximum of $100
natal visits If the physician per 12-month period(*) per
charges separately for such visits family.
in addition to the charge for
delivery, and paragraphs (g)
through (m), paragraph (n) except
inpatient surgery, paragraph (o)
and Section A(7) paragraph (f).

*The 12-month periods shall begin on the following dates: March 27, 1988; March 27, 1989; March 27, 1990; March 27, 1991 and March 27, 1992.


When a Beneficiary is confined as an inpatient in a hospital because of illness or Injury, Article III. A (3)(g) of the Employer Benefit Plan provides benefits for in hospital visits by the physician in charge of the case. In addition, Article III. A. (3) (I) and Article III. A. (3)(m) provide benefits for medical consultation services and specialist care.

Article III. A. (8) states that certain benefits provided in the Plan shall be subject to co-payments which are the responsibility of the Beneficiary. Among those benefits are the inpatient physician’s services described in paragraphs (g), (I) and (m) of Article III. A. (3), as reproduced above. The co-payment for these services is $7.50 per visit, up to a maximum of $150 per 12-month period per family for Employees described in Article II. A and Article II. C (3).

The Employer has certified that the Complainant was an active Employee as described in Article II. A. at the time of his spouse’s hospitalization. Therefore, each physician visit covered under Article III. A (3)(g), (I) or (m) during her hospitalization is subject to a $7.50 co-payment until the plan year maximum has been met.

Opinion of the Trustees

The Employer was correct in assessing a $7.50 co-payment on all physician’s in hospital visits until the plan year maximum was reached. Such co-payments are the responsibility of the Employee.