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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-698 – December 15, 1993

Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for inpatient treatment for alcoholism and drug abuse under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s eighteen-year-old son was voluntarily hospitalized from November 14 through December 14, 1990, in an inpatient treatment facility, for alcohol detoxification and treatment of alcohol and drug abuse. The Employee states that the hospitalization took place without his knowledge; that the son was living apart from the Employee following a divorce. The facility’s clinical assessment notes that the Complainant’s son had admitted to his employer that he was “using” (drugs and alcohol), and that his employer had encouraged him in his decision to seek help. The medical discharge summary stated that the patient was admitted overnight to the detoxification unit for observation, and then transferred to the residential treatment program for the remaining 29 days. The discharge summary listed the diagnoses as cocaine dependency, marijuana dependency, and alcoholism.

The Employer provided benefits for the first seven days of hospitalization, for alcohol and drug abuse, between November 14 and November 20, 1990, and denied benefits for the remaining 23 days of hospitalization.

Dispute

Is the Employer required to provide benefits for the Complainant’s son’s entire hospitalization for treatment of alcoholism and drug abuse?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the Complainant’s son’s entire inpatient confinement for alcoholism and drug abuse because the hospitalization was medically necessary.

Position of the Employer: The Employer is not required to provide benefits for the Complainant’s son’s inpatient treatment beyond November 20, 1990, because Article III. A. (1) (f) of the Employer Benefit Plan limits the duration of benefits for inpatient treatment of alcoholism and drug abuse to seven calendar days.
Pertinent Provisions

The Introduction to Article III states in pertinent part:

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. (I)(e) and (f) of the Employer Benefit Plan state in pertinent part:

(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.

(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 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.

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Discussion

The Introduction to Article III of the Employer Benefit Plan provides benefits for services which are reasonable and necessary for the diagnosis and treatment of an illness and which are given at the appropriate level of care, or are otherwise provided for under 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)(f) of the Plan provides inpatient hospitalization benefits for a Beneficiary who requires emergency detoxification for treatment of alcoholism, or emergency treatment for drug abuse for a maximum of seven 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 Plan provides 30 days of inpatient hospitalization benefits for a Beneficiary who is confined for treatment of mental illness. Article III. A. (7)(f) of the Plan provides benefits for outpatient treatment of alcoholism or drug abuse.

In this case, the Complainant’s son admitted himself to a alcohol and drug treatment program. No contact was made with the Complainant’s Employer, or its claims administrator, prior to the admission to inquire about benefits for this type of hospitalization, or to seek guidance regarding any possible hospital pre-certification program that would require additional action on the part of either the Complainant or his son. The request for Resolution of Dispute noted that the Complainant was not aware that his son had been admitted to the hospital treatment program; the son was living apart from the Complainant following a divorce.

The information received indicates that the Complainant’s son was placed in the facility’s detoxification unit one night for observation and was then transferred to a normal adolescent semi-private room where he stayed until his discharge. He received family therapy, group therapy, individual therapy, and clinical testing and assessment. He was discharged with orders to actively participate in a program like Alcoholics Anonymous.

The Employer provided benefits for the first seven days of hospitalization, but denied benefits for the remaining 23 days.

A Funds’ medical consultant has reviewed this case to include the admission and discharge summaries, psychosocial evaluation, clinical assessment, and the routine psychological screening, as well as progress notes, laboratory results, and the counselor’s treatment summary. The medical consultant noted that the records state that the Complainant’s son was admitted for treatment of drug and alcohol abuse which had progressed to the point of interfering with his work. The consultant noted additionally that the treatment program was not intense, and that, in his opinion, the psychosocial problems of the patient did not require inpatient psychiatric treatment.

In RODs 88-341 and 88-127 (copies enclosed herein), the Trustees decided that an Employer was only required to provide benefits for the first seven days of an admission for drug and alcohol detoxification.

Inasmuch as the Employee’s son 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.

Opinion of the Trustees

The Employer is not required to provide additional benefits for the Employee’s son’s inpatient treatment for alcohol and drug dependency, from November 14 through December 14, 1990.