受托人的意见
争议的解决
情况下没有. 84-723
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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
84-723 - 1991年2月28日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee: William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 for inpatient treatment for drug abuse for an 员工’s spouse under the term; of 雇主福利计划.

背景事实

The 员工’s spouse was hospitalized from November 20, 1986年至12月18日, 1985年治疗处方药成瘾. The 雇主 provided benefits for the first 7 days of the 员工’s spouse’s hospitalization, 但在剩下的停留时间里，福利被拒绝了, 说明根据雇主福利计划, benefits are provided for up to 7 days for emergency inpatient treatment for alcoholism and drug abuse. 在8月30日的信中, 1990, a physician affiliated with the hospital’s substance abuse services states that the 员工’s spouse’s prospect for recovery would have been greatly reduced had she been hospitalized for only 7 days, 因此, a longer period of hospitalization was medically necessary.

争端

Is the 雇主 required to provide benefits for more than the first 7 days of the 员工’s spouse’s inpatient treatment for drug abuse:

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the entire period of the 员工’s spouse’s inpatient treatment for drug abuse because a physician determined that an extended stay was medically necessary,

Position of the 雇主: The 雇主 is not required to provide benefits for more than the first 7 days of the 员工’s spouse’s treatment because benefits for inpatient treatment of alcohol and drug abuse are limited to 7 calendar days per admission under 第三条. A. (1) (f)

受托人解决争议意见. 84-723
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雇主福利计划, and there is no indication that treatment of any other medical or mental condition was provided.

第三条有关规定. A. 雇主福利计划第(1)(f)条规定:

(1)住院医疗福利

(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.

See paragraph (7)(f) for information concerning other services related to treatment of alcoholism and drug abuse.

第三条. A. (7)(f) of 雇主福利计划 states in pertinent part (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, group therapy and alcoholism or drug rehabilitative programs where free care sources are not available and when determined to be medically required by a physician.

讨论

第三条. A. (1) (f) 雇主福利计划 provides benefits for inpatient treatment of alcoholism and drug abuse when a Beneficiary requires emergency detoxification for the treatment of alcoholism or emergency treatment for drug abuse for a maximum of T calendar days per admission. If inpatient treatment of a medical or mental condition is necessary following detoxification or emergency treatment for drug abuse, benefits may be payable under other provisions of the Plan. 此外，第三条. A. (7)(f) of 雇主福利计划 provides benefits for outpatient treatment of alcoholism or drug abuse.

受托人解决争议意见. 84-723
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The 员工’s spouse was hospitalized from November 20, 1986年至12月18日, 1986 for treatment of addiction to a prescription drug. The 雇主 paid the charges for the first 7 days of treatment, but denied payment for the remainder of the hospitalization. A physician affiliated with the hospital’s substance abuse services has stated that hospitalization beyond the first 7 days was medically necessary to improve the 员工’s spouse’s prospects for recovery. A Funds’ medical consultant has reviewed this case and has advised that the documentation provided indicates that the inpatient admission in this case was for treatment of drug abuse. 根据顾问的说法, there is no documentation that inpatient care was required for treatment of other medical or mental conditions during this admission. Inasmuch as the 员工’s spouse received inpatient hospital care for the treatment of drug abuse, the 雇主 is not required to provide benefits for services rendered beyond the first 7 days of the 员工’s spouse’s hospitalization, 符合第三条的规定. A. (1)(f)计划.

受托人的意见

The 雇主 is not required to provide benefits for more than 7 days of the 员工’s spouse’s hospitalization for treatment of drug abuse.