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OPINION OF TRUSTEES _____________________________________________________________________________
在再保险
Complainant: Respondent: ROD Case No:
员工
雇主
84-614——1988年6月6日
Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, 受托人审查了这一争议的事实和情况，该争议涉及根据雇主福利计划的条款为酗酒和戒毒康复服务提供健康福利.
背景事实
雇员的配偶自3月13日起在一家医院的酒精和化学品依赖治疗科住院治疗, 1987年至4月24日, 1987. 出院摘要指出，她的主要诊断是酒精依赖综合症，其次诊断为多种药物滥用和抑郁症并发症. The 员工 claims that before his spouse entered the program, 他和医院计费部门的一名代表分别打电话给计划管理员，询问住院的保险范围. He alleges that they were both told that the charges for the hospitalization would be paid in full by the 雇主. The 员工 claims that the 雇主 advised the representative of the hospital billing department that benefits would be provided for 7 days of inpatient treatment for alcoholism and drug abuse; the hospital would need to bill for an additional medical problem, such as stress and depression, in order for the 雇主 to provide additional benefits.
The 员工’s wife states that depression and stress brought on her alcoholism. 她还说，经过几周的治疗后，一位精神病医生对她进行了评估，并开始治疗她的抑郁症. 她认为，医院错误地向保险公司收取了治疗酗酒和滥用药物的费用，并且医院拒绝将该账单作为治疗压力和抑郁症的费用重新提交.
The 雇主 originally paid the charges for the 员工’s spouse’s entire hospitalization, 减去个人物品. During a routine audit of claims, it determined that under 第三条. A. (1)(f)计划, benefits for inpatient hospitalization for alcohol detoxification are limited to 7 calendar days. Based on the diagnosis of “alcohol dependency, 多重药物依赖,” as stated on the hospital bill, the 雇主 denied benefits for the 员工’s spouse’s
Opinion of Trustees Resolution of 争端 Case No. 84-614
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hospitalization beyond the 7 calendar days specified under the Plan. The 雇主 requested and received a refund from the hospital of amount denied.
争端
雇主是否有责任支付雇员配偶在3月19日以后住院戒酒和戒毒治疗的费用, 1987?
双方立场
乙方职位:乙方配偶3月19日以后的住院费用由甲方承担, 1987, because she was being treated for depression and stress in addition to her alcohol and drug dependency.
聘方立场:聘方不负责支付3月19日以后的住院费用, 1987, 因为第三条. A. (1)雇主福利计划(f)将提供酗酒或滥用药物住院治疗的健康福利限制为7个日历日.
Pertinent Provisions 第三条. A. (1)(e) and (f) of the 雇主 Benefit Plan states:
(1) Inpatient Hospital Benefits (e) Mental Illness
对于因精神疾病而被有执照的精神病医生限制在医院的受益人，可提供最多30天的津贴. 当医疗需要时, 患有急性(短期)精神疾病的住院治疗最多可延长30天, 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, (即使分娩的第一天发生在先前的工资协议期间)在本计划中被视为慢性(长期)精神问题，本计划不提供住院治疗福利)。.
(f) Alcoholism and Drug Abuse
为需要医院紧急戒毒治疗酗酒或吸毒紧急治疗的受益人提供津贴. Such treatment is limited to 7 calendar days per inpatient hospital admission.
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在戒毒或药物滥用紧急治疗后需要治疗医疗或精神状况的, 福利可根据本计划的其他条款提供，并受该等条款的任何要求或限制的约束.
See paragraph (7)(f) for information concerning other services related to treatment of alcoholism and drug abuse.
第三条. A. (7)(f) of the 雇主 Benefit Plan states: (7) Other Benefits
(f) Outpatient Mental Health, Alcoholism and Drug Addiction
Benefits are provided for:
心理治疗, 心理测试, 咨询, 团体治疗和酗酒或药物康复方案，在没有免费护理来源的情况下，当医生确定有医疗需要时.
Benefits are not provided for:
第三条. A. (1)雇主福利计划(f)为需要紧急戒毒治疗酗酒或吸毒紧急治疗的受益人提供每次入院最多7个日历日的住院治疗津贴. If treatment of a medical or mental condition is necessary 解毒后, benefits may be payable under other provisions of the Plan. 第三条. A. 雇主福利计划(1)(e)为因精神疾病而受限制的受益人提供住院治疗福利. 此外，第三条. A. (7)(f) of the 雇主 Benefit Plan provides benefits for outpatient treatment of alcoholism or drug abuse.
Opinion of Trustees Resolution of 争端 Case No. 84-614
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该雇员的配偶在酒精和化学品依赖治疗(ACT)住院治疗42天，以治疗酒精和药物依赖. The 雇主 paid the charges for the first 7 days of treatment, but denied payment for the remainder of the hospitalization. 尽管雇员的配偶辩称，她的住院费用应全额支付，因为她接受了压力和抑郁症治疗, 没有证据表明, 解毒后, she required inpatient confinement for treatment for mental illness, for which benefits may be provided under 第三条. A. (1)(e). 而, 向雇员配偶提供的治疗是为酒精/化学品依赖患者设计的，基于包括医疗解毒在内的多学科方法, 个别咨询, Alcoholics Anonymous meetings, psychiatric evaluation and treatment, 物理治疗, recreation therapy and other services. 此外, because the treatment was rendered in an inpatient (rather than outpatient) program, the 雇主 is not responsible for providing health benefits under 第三条. A. (7)(f). 因为该雇员的配偶因治疗酒精和药物依赖而接受住院治疗, 雇主不负责提供雇员配偶自3月13日起住院治疗费用以外的住院治疗费用, 1987年至3月19日, 1987, consistent with the terms of 第三条. A. (1)(f)计划.
受托人的意见
雇主不负责为雇员配偶因酒精和药物依赖而住院治疗提供任何额外福利.