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OPINION OF TRUSTEES ______________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
84-660——1988年9月27日

董事会: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, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for inpatient chemical dependency treatment 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 dependent daughter was hospitalized for treatment for chemical dependency from April 14, 1987年至5月14日, 1987. 雇员说，在他女儿被收容之前, the manager of insurance and billing at the hospital called the 雇主’s insurance carrier to verify coverage for his daughter’s hospitalization. The 员工 claims that the carrier’s representative advised that coverage would be provided for 7 days of the inpatient hospitalization.

The 雇主 subsequently denied benefits for the hospitalization because the facility was not an accredited hospital.

The 员工 asks whether the 雇主 is responsible for providing benefits for the first 7 days of his daughter’s inpatient chemical dependency treatment.

争端

Is the 雇主 responsible for providing benefits for the first 7 days of the 员工’s dependent’s inpatient chemical dependency treatment?

双方立场

Position of the 员工: The 雇主 is responsible for providing benefits for the first 7 days of the 员工’s dependent’s inpatient chemical dependency treatment because it is a covered

受托人解决争议意见. 第2页

benefit under the 雇主 Benefit Plan and the 雇主’s insurance carrier had indicated that it would be covered prior to the admission.

Position of the 雇主: The 雇主 is not responsible for providing benefits for the 员工’s dependent’s inpatient chemical dependency treatment because the facility was not an accredited hospital.

相关的规定
第三条. A. 雇主福利计划的(1)(a)、(f)和(i)相关部分说明:

(1)住院津贴(a)半私人病房

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.

.. .

(f)酗酒和滥用药物

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.

(我)一般

Accredited Hospital is a hospital which is operated primarily for the purpose of rendering inpatient therapy for the several classifications of medical and surgical cases and which is approved by the Joint Commission on Accreditation of Hospitals or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.

受托人解决争议意见. 第3页

讨论

第三条. A. (1)(f) of the 雇主 Benefit Plan provides benefits for emergency detoxification hospital care for the treatment of alcoholism or emergency treatment for drug abuse for up to 7 calendar days per inpatient hospital admission. 第三条. A. (1) (a) and (i) stipulate that the term “hospital” as used throughout the Plan refers to a hospital that is approved by the Joint Commission on Accreditation of Hospitals (JCAH) or which has been approved by the Trustees of the United Mine Workers of America 1950 Benefit Plan and Trust.

尽管雇员声称, 在他女儿入院之前, hospital staff were advised that benefits would be paid for the first 7 days of his daughter’s hospitalization, there is no indication that either the 员工 or the provider was misled regarding the coverage requirements of 第三条. A. (1)(f)计划. The information submitted indicates that the carrier’s representative discussed coverage available under the 雇主 Benefit Plan with the hospital’s staff, 而不是具体案例是否符合该覆盖的标准.

雇主拒绝支付雇员女儿的住院费用, stating that the hospital is not approved by the JCAH as a hospital operated primarily for the purpose of rendering in-patient therapy for several classifications of medical and surgical cases. 虽然该设施没有被认可为综合医院, 它是JCAH认可的专科医院, 并获得了俄亥俄州卫生部的许可, 用于治疗依赖化学物质的个体.

受托人的意见

The 雇主 is responsible for providing medically necessary benefits for the 员工’s dependent’s first 7 days of inpatient chemical dependency treatment.