____________________________________________________________________________
OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
93-110 – November 14, 2001
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 benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant is employed by the Respondent and is eligible for health benefits coverage as an active employee. According to a court order entered on January 7, 1997, the Complainant was to enroll in an addiction treatment center “at his own expense for a period not to exceed sixty
days . . . .” The order further stated that the Complainant “shall not leave said Center under any circumstance until he has completed the program. . . .” The Complainant entered the treatment center on January 8, 1997, and was discharged on January 22, 1997. The Respondent has denied coverage for the Complainant’s treatment.
Dispute
Is the Respondent required to provide coverage for the Complainant’s stay at an addiction treatment center from January 8, 1997, to January 22, 1997?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide coverage for the Complainant’s stay at the addiction treatment center because the treatment was court ordered and the Complainant successfully completed the treatment program.
Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s stay at the addiction treatment center because the Complainant was not considered a good candidate for rehabilitation. Furthermore, the court order does not supercede the Employer Benefit Plan’s provisions regarding coverage for substance abuse.
Opinion of Trustees ROD Case No. 93-110 Page 2
Pertinent Provisions
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) (f) states in pertinent part:
ARTICLE III BENEFITS
A. Health Benefits
(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.
Opinion of Trustees ROD Case No. 93-110 Page 3
Discussion
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.
A Fund’s medical consultant has reviewed the information submitted which includes the court order and medical records from the treatment center. The consultant notes that there is no documentation submitted that indicates that a physician determined that the Complainant’s stay at the treatment center was medically necessary for emergency detoxification. The consultant concludes that the Complainant’s treatment would not be covered under Article III A. (1) (f) of the Employer Benefit Plan.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Respondent is not required to provide benefits for the Complainant’s stay at an addiction treatment center from January 8, 1997, to January 22, 1997.