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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
88-730 – February 6, 1995
Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for inpatient treatment for alcoholism and substance abuse under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s seventeen-year-old dependent daughter was treated in a hospital’s chemical dependency unit from September 9, 1991 through October 8, 1991. The hospital records indicate that the patient was admitted for alcohol dependence and inhalant abuse (nitrous oxide) with a history of bronchial asthma. According to the hospital records, the Employee’s daughter needed no medical detoxification. The discharge diagnosis was alcohol dependence, adjustment disorder with depressed mood and bronchial asthma.
The Employer provided benefits for the first seven days of hospital confinement under Article III. A. (1)(f) of the Employer Benefit Plan, but denied benefits for the remaining days of hospitalization.
The Employee contends that he was led to believe by the provider and the insurance carrier that the entire 30 days of treatment would be covered. Further, the Employee states that his daughter was treated for other psychiatric disorders that would qualify for benefits beyond the seven days of hospitalization provided under Article III. A. (1)(f).
Healthlink, an organization providing utilization review services for the Employer, had certified the Employee’s daughter’s admission as “medically necessary” by letter dated September 11, 1991. The letter states that such confirmation does not confirm eligibility for coverage or guarantee payment of benefits. The letter refers the Employee and providers to the insurance carrier or claims administrator for benefit and eligibility information.
The Employer states that the hospital was informed that only seven days of coverage would be provided, and evidence that the family was advised of the limitation is contained in the hospital record.
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Dispute
Is the Employer required to provide benefits for more than seven days of inpatient hospitalization in connection with the Employee’s daughter’s treatment for alcohol dependence?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s daughter’s inpatient treatment because she was treated for a mental condition in addition to substance abuse and because the Employee was led to believe that 30 days of inpatient coverage would be provided.
Position of the Employer: The Employer is not required to provide benefits for more than the first seven days of the Employee’s daughter’s treatment because benefits for inpatient treatment of alcohol and drug abuse are limited to seven calendar days per admission and there is no indication that any other medical or mental treatment was provided during the course of her confinement.
Pertinent Provisions Article III. A. (1)(f) of the Employer Benefit Plan states:
(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.
Discussion
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 seven calendar days per admission. If inpatient treatment of a medical or mental condition is necessary following the treatment for substance abuse, benefits may be payable under other provisions of the Plan.
A Funds’ medical consultant has reviewed the file on this case, which contains portions of the hospital record, and notes that the discharge summary contains the medical opinion that the
Opinion of Trustees
ROD Case No. 88-730
Page 3
patient did not meet the criteria for a diagnosis of major depression. Additionally, the discharge summary noted that the patient did not require medical detoxification, and was discharged with the diagnoses of alcohol dependency, adjustment disorder with depressed mood, and bronchial asthma. He is of the opinion that there is inadequate medical documentation of the need for further inpatient psychiatric care following the initial seven days of treatment for alcohol abuse, and thus, the extended hospitalization does not meet the criteria for 30 days of inpatient psychiatric care as provided under Article III.A.(1)(c) and (f) of the Plan.
The issue of the admission certification provided by HealthLink has been raised. The admission certification letter sent to the Employee, and copied to the admitting physician, states that “this notification does not confirm eligibility for coverage or guarantee payment.” Additionally, the hospital pre-certification program through the Employer is voluntary.
The Employer has furnished a copy of a concurrent review form completed by HealthLink via a telephone conversation with a nurse at the hospital. This form confirms that the Employee and his spouse were told, and notes that they were upset, that only seven days of inpatient benefits were available for an admitting diagnosis of chemical dependency.
The Trustees are of the opinion that the Employer is not required to provide benefits beyond the initial seven days of inpatient hospitalization provided for in Article III.A.(1)(f) of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s daughter’s confinement for alcohol abuse in excess of the seven days of inpatient hospitalization provided for in Article III.A.(1)(f) of the Employer Benefit Plan.