OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
88-833 – January 23, 1997
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 health benefits coverage for inpatient mental illness treatment under the terms of the Employer Benefit Plan.
On April 29, 1993, the Employee entered an addiction recovery unit via self referral following a second conviction within one year for driving under the influence. He remained there until May 11, 1993. He had been taking medication for depression for several months prior to this hospitalization.
The Employer provided benefits for seven days of detoxification, but denied benefits for the last five days of the Employee’s hospitalization as beyond the seven calendar days authorized under the Plan.
The Employer was signatory to the National Bituminous Coal Wage Agreement (Wage Agreement) of 1988 which terminated on February 1, 1993. A representative for the Employee states that following the expiration of the Wage Agreement, the UMWA and the Employer continued negotiations and the Employer was not affected by a strike. The Employer is signatory to the Wage Agreement of 1993.
Is the Employer required to provide benefits for the Employee’s hospitalization from May 6, 1993 through May 11, 1993, the last five days of his hospitalization?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s hospitalization for five days beyond the seven days of detoxification treatment because he was being treated for depression.
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Position of the Employer: The Employer is not required to provide benefits for the extended hospitalization because the Employee Benefit Plan limits the provision of health benefits for inpatient treatment of alcoholism to seven calendar days.
The Introduction to Article III of the Employer Benefit Plan 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. (1) (e) and (f) state: Article III Benefits
A. Health Benefits
(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. (More than 90 days of confinement for mental illness over a two-year period, (dating from the first day of hospital confinement, even if the first day of confinement occurred during a prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide 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
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provided under other provisions of this Plan and are subject to any requirements or limitations in such provisions.
The Introduction to Article III provides benefits for medically necessary services. Article III A. (1) (f) provides inpatient hospitalization benefits for a Beneficiary who requires emergency detoxification for the treatment of alcoholism 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 Employer Benefit Plan provides inpatient hospitalization benefits for a Beneficiary who is confined for treatment of mental illness.
The Employee was admitted to an inpatient addiction recovery unit for 12 days for the treatment of alcohol dependency. The Employer paid the charges for the first seven days of treatment, but denied payment for the remainder of the hospitalization.
A Fund’s medical consultant has reviewed the documentation submitted and has concluded that although the initial assessments of the patient indicate an on-going problem with depression, there is no documentation in the medical records provided of the severity of this problem that would require inpatient acute psychiatric care. Therefore, the Employer is not required to provide benefits beyond the seven calendar days provided under the Plan.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the last five days of the Employee’s admission.