Opinion of Trustees
Resolution of Dispute
Case No. 81-447
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OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article IX of the United Mine Workers of America 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 level of health benefits for the Employee’s son under the Employer’s Benefit Plan. They hereby render their opinion in the matter.
Background Facts
The Employee’s son was hospitalized to determine whether the cause of his longstanding multiple medical problems (i.e., hyperactivity, hypogonadism, enuresis, obesity, mental retardation, etc.) is a condition known as Prader-Willi Syndrome. The Employer has denied payment for the hospital, outpatient, and professional charges resulting from this care.
Question or Dispute
Is the Employer responsible for payment of the charges resulting from the Employee’s son’s medical care?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of the charges resulting from the Employee’s son’s inpatient and outpatient care.
Position of the Employer: Payment for these services has been denied because Article III A. (11) (a) 17. of the Employer’s Benefit Plan states that charges for medical services for inpatient or outpatient treatment for mental retardation and other mental deficiencies are excluded from coverage.
Employee
Employer
81-447 – Nay 29, 1984
Opinion of Trustees Resolution of Dispute Case No. 81-447
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Pertinent Provisions Article III A. (1) (a) of the Employer’s Benefit Plan states:
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.
Medically necessary services provided in a hospital include the following:
Operating, recovery, and other treatment rooms
Laboratory tests and x-rays
Diagnostic or therapy items and services
Drugs and medication (including take-home drugs which are limited to a 30-day supply)
Radiation therapy
Chemotherapy Physical therapy
Anesthesia services
Oxygen and its administration
Intravenous injections and solutions
Administration of blood and blood plasma
Blood, if it cannot be replaced by or on behalf of the Beneficiary
Article III A. (3) (9), (h) and (l) of the Employer’s Benefit Plan state:
If a Beneficiary is confined as an inpatient in a hospital because of an illness or injury, benefits are provided for inhospital 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.
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.
Opinion of Trustees Resolution of Dispute Case No. 81-447
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(l) Medical Consultation
Benefits are provided for services rendered, at the request of the 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.
Article III A. (11) (a) 17 of the Employer’s Benefit Plan states:
III:Benefits
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
17. Charges for medical services for inpatient or outpatient treatment for mental retardation and other mental deficiencies.
Discussion
Article III A (1) (a) provides benefits for inpatient hospital services that are medically necessary for the diagnosis and treatment of a Beneficiary’s condition. Coverage for physician’s services rendered in a hospital, office, clinic, or home is provided by Article III A. (3) (g), (h), and (l) of the Plan.
A Funds’ medical consultant has reviewed the information contained in the file regarding the disputed issue in this case. Based on that review, the consultant determined that the hospital and physician services provided to the Employee’s son were not for the treatment of mental retardation or other mental deficiencies which are specifically excluded from coverages under Article III. A. (11) (a) 17. Although the Employee’s dependent’s condition may manifest one or more of these specific problems, the medical care he received was to establish the diagnosis and/or etiology of his condition and to provide clinical guidance regarding his hypogonadism along with medical treatment of his enuresis.
Since the Employee’s son was under a physician’s care for the purpose of establishing a diagnosis of his multiple medical problems and not for the treatment of mental retardation or other mental deficiency, the Employer is responsible for payment of the charges related to this care.
Opinion of the Trustees
A. Health Benefits
(11) General Exclusions
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The Employer is responsible for the payment of charges resulting from the Employee’s dependent’s inpatient and outpatient care in this instance.