OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
CA-031 – March 23, 1999
A. Frank Dunham, Michael H. Holland, Marty D. Hudson and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency detoxification under the terms of the Coal Industry Retiree Health Benefits Act of 1992 (Coal Act) Employer Benefit Plan, maintained pursuant to section 9711 of the Internal Revenue Code.
On May 29, 1996, the Pensioner was admitted to the hospital for treatment of his alcohol abuse and dependency. At the time of admission he was intoxicated, and was immediately started on detoxification medication. During his stay, he participated in group and individual therapy and attended Alcoholics Anonymous meetings. He was discharged on June 10, 1996.
Medicare Part A applied its $736.00 inpatient deductible and provided benefits for the remaining charges for the Pensioner’s admission. The Employer has denied benefits for the $736.00 balance, citing non-duplication of benefits and the seven day limitation on detoxification hospitalizations.
Is the Employer required to provide benefits for the Pensioner’s $736.00 Medicare Part A Deductible?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the admission because it was emergency treatment for alcohol abuse.
Position of the Employer: The Employer is not required to provide benefits for the admission under the non-duplication of benefits provision and because the admission exceeded the seven days allowed for emergency treatment of alcohol abuse.
Opinion of Trustees ROD Case No. CA-031 Page 2
Article III A. (1) (f) of the Coal Act Employer Benefit Plan states, in pertinent part: A. Health Benefits
1. Inpatient Hospital Benefits
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(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.
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Article III A. (10) (d) and (f) 1. (i) and (ii) of the Coal Act Employer Benefit Plan state:
(10) General Provisions (d) Medicare
For Pensioners, and surviving spouses, the benefits provided under the Plan will not be paid to a Beneficiary otherwise eligible if such Beneficiary is eligible for Hospital Insurance coverage (Part A) of Medicare where a premium is not required and/or Medical Insurance coverage (Part B) of Medicare unless such Beneficiary is enrolled for each part of Medicare for which such Beneficiary is eligible. Any such Beneficiary who is enrolled in a Medicare program shall receive the benefits provided under the Plan only to the extent such benefits are not provided for under Medicare.
Opinion of Trustees ROD Case No. CA-031 Page 3
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The health benefits provided under this Plan are subject to a non- duplication provision as follows:
1. Benefits will be reduced by benefits provided under any other group plan, including a plan of another Employer signatory to the Wage Agreement, if the other plan:
(i) does not include a coordination of benefits or non- duplication provision, or
(ii) includes a coordination of benefits or non-duplication provision and is the primary plan as compared to this Plan
*** *** *** Discussion
Article III A. (1) (f) of the Coal Act Employer Benefit Plan provides inpatient emergency treatment of alcohol abuse. Article III A. (10) (d) of the Plan requires that Pensioners enroll in Medicare Part A and Part B if eligible. If enrolled, benefits are provided under the Employer Benefit Plan only to the extent that such benefits are not provided under the Medicare Program.
The Pensioner is enrolled in the Medicare Program as required by Article III A. (10) (d) of the Plan and is entitled to benefits under the Plan for covered services for which Medicare does not provide benefits. The Plan provides benefits for emergency detoxification hospital care. In this case, the Medicare Program provided benefits for all hospital charges after its $736.00 deductible. Because the deductible is incurred at the beginning of the admission, it is a covered benefit under the terms of the Plan which was not provided by Medicare.
Accordingly, the seven-day limitation on emergency detoxification hospital care is not an issue in this case. Also, because the deductible is covered under the Coal Act Employer Benefit Plan but not Medicare, there is no duplication of benefits issue. Therefore, the Employer is required to provide benefits for the Pensioner’s $736.00 Part A Deductible, subject to the appropriate co- pay and deductible provisions of the Coal Act Employer Benefit Plan.
Opinion of Trustees ROD Case No. CA-031 Page 4
Opinion of the Trustees
Consistent with the policies and provisions of the Coal Act Employer Benefit Plan, the Employer is required to provide benefits for the Pensioner’s $736.00 Part A Deductible, subject to the appropriate co-pay and deductible provisions of the Coal Act Employer Benefit Plan.