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OPINION OF TRUSTEES _____________________________________________________________________________
在再保险
投诉人:被投诉人:ROD案件编号:
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee and Donald E. 皮尔斯,受托人.
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 provision of benefits coverage for mental illness under the terms of the 雇主 Benefit Plan and hereby render their opinion on the matter.
背景事实
The 员工’s spouse was confined in a hospital for mental illness for the following periods: October 4, 1982年至10月28日, 1982; April 28, 1983年至5月27日, 1983, 6月19日, 1983年至6月25日, 1983年和5月7日, 1984年至6月14日, 1984. The total number of days of hospitalization billed for during these admissions is ninety-seven (97).
The 雇主 has paid for all periods of confinement except for seven (7) days: June 8, 1984年至6月14日, 1984.
争端
Is the 雇主 responsible for payment of charges for hospitalization for mental illness from June 8, 1984, 到6月14日, 1984?
各方立场
Position of 员工: The 雇主 should pay the charges for the 员工’s spouse’s hospitalization for the periods from June 8, 1984, 到6月14日, 1984, especially since a consulting physician provided care to the patient during the May 7, 1984, 到6月14日, 1984年入学.
员工
雇主
81-598——1985年6月24日
Opinion of Trustees Resolution of 争端 Case No. 81-598页
Position of 雇主: The 员工’s spouse was confined for more than 90 days for mental illness in the two-year period prior to June 8, 1984; 因此, she was not eligible for benefits for the period June 8, 1984, 到6月14日, 1984.
相关的规定
第三条. A. (1) (e)雇主福利计划 which provides:
e. 精神疾病
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. 当医疗需要时, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short- term) mental illness, 每一次急性疾病. (More than 90 days of confinement for mental illness over a two-year period (dating from the first day of hospital confinement) 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.)
问与答(“Q”&A”)第81-6条规定:
The inpatient hospital benefit for mental illness limits the number of covered days as follows:
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. 须经受托人批准, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, 每一次急性疾病. (More than 90 days of confinement for mental illness over a two-year period (dating from the first day of hospital confinement> is deemed for purposes of the Plan to be a chronic (long-term) mental problem for which the Trustees will not provide inpatient hospital benefits.)
How is the limit of “90 days over a two-year period” to be interpreted? 答:
The limit refers to the cumulative number of days of inpatient hospital care for all mental illness diagnoses, 不考虑每一次急性发作.
The two-year period begins on the first day of an inpatient hospital stay for a mental problem and ends two full years later.
Opinion of Trustees Resolution of 争端 Case No. 第3页
讨论
根据第三条. A. (1) (e)雇主福利计划, benefits are not provided for inpatient hospital confinements for chronic mental illness. An individual is deemed to have chronic mental illness if he/she is confined for more than 90 days over a two-year period, dating from the first day of hospital confinement. 根据Q&A #81-6, the limit of “90 days over a two year period” is interpreted as the cumulative number of days of inpatient hospital care for all mental illness diagnoses, 不考虑每一次急性发作.
The information submitted to the Trustees indicates the 员工’s spouse was confined in a hospital for mental illness for more than 90 days during the two-year period following her first day of confinement in October 1982. Therefore, the spouse is deemed to have chronic mental illness.
The 员工 has contended that the days on which his spouse received care for another illness, 除了她的主治医生, 从5月7日到6月14日, 1984年入院, fall under other coverage provisions of the Plan and, 因此, should not be considered in calculating her eligibility for benefits under the inpatient mental illness benefit. Because the consulting physician was called in during this patient’s hospitalization for mental illness to provide only limited care for a skin condition, this factor has no bearing on the 员工’s spouse’s eligibility limitation for inpatient mental illness benefits, nor does it alter the reason for her admission.
受托人的意见
The Trustees are of the opinion that the 雇主 is not responsible for providing in-patient hospital benefits for the 员工’s spouse for the period from June 8, 1984, 到6月14日, 1984.