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受托人的意见
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在再保险

原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 07-0021

受托人: 迈克尔W. 丹尼尔·L·巴克纳. Fassio和Michael H. 荷兰.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

投诉人从1974年养老金信托皇冠搏彩中心网站领取55岁养老金 with an effective date of May 1, 2004. 2005年底, the Respondent sent notices to its 养老金领取者s informing them that to keep their health benefits all 医疗保险 eligible individuals must enroll in 医疗保险A部分, B和D.

申诉人在3月1日成为符合医疗保险资格的人时，正在接受雇主的医疗福利, 2006, 因为领取了社会保障残疾保险. 投诉人在获得医疗保险资格时没有参加医疗保险B部分, claiming he did not know that he needed to be enrolled in 医疗保险B部分 in order to keep his health benefits from the Respondent, 但他确实在2006年4月参加了医疗保险D部分.

2007年3月, 投诉人联系被投诉人安排报销他的医疗保险D部分保费, 当时索赔人告知被告他没有参加联邦医疗保险B部分. The Respondent terminated Complainant’s health benefits effective April 2007 for failure to enroll in 医疗保险B部分.

投诉人已于2008年7月1日加入联邦医疗保险B部分. 被投诉人同意从2008年7月起偿还投诉人的医疗保险D部分保费, but asserts that the Complainant is not entitled to reimbursement for the Part D premium paid at the time he was eligible for, 但没有注册, B部分.

争端

Is the Respondent responsible for reimbursing the Complainant for 医疗保险 Part D premiums for the time Complainant was eligible for, 但没有注册, 医疗保险B部分?

双方立场

投诉人的立场:被投诉人要求参加医疗保险D部分和, 因此, 是否应偿还投诉人已缴付的所有保费.

Position of the 被申请人: 原告 is not entitled to reimbursement for the 医疗保险 Part D premiums during the time he was eligible for, 但没有注册, 医疗保险B部分.

相关的规定
第三条. A. 雇主福利计划第(10)(d)条规定:

第三条福利待遇

A. 健康的好处
(10)总则
(d) 医疗保险

1. 针对养老金, 以及幸存的配偶, the benefits provided under the Plan will not be paid to a Beneficiary otherwise eligible if such Beneficiary is eligible for Hospital Insurance coverage (Part A) of 医疗保险 where a premium is not required and/or Medical Insurance coverage (B部分) of 医疗保险 unless such Beneficiary is enrolled for each part of 医疗保险 for which such Beneficiary is eligible. Any such Beneficiary who is enrolled in a 医疗保险 program shall receive the benefits provided under the Plan only to the extent such benefits are not provided for under 医疗保险.

2. For Employees age eligible for 医疗保险 the benefits provided under the Plan will be paid to a Beneficiary unless the company is furnished written notice of electing coverage under 医疗保险 rather than coverage under the Plan. 或者，参与者可以选择参加医疗保险作为次要付款人.

计划管理人应就1的登记义务发出书面通知. 以上和选择注册相对于2. 以上. 对于在职员工，此类通知应在其符合医疗保险资格的生日之前发出, 而是在他们刚过完生日之后. Said notice shall explain the limited annual enrollment period and the effect of failing to enroll if retirement should occur prior to the next enrollment period. 未提供此类通知不免除任何注册义务.

讨论

The Respondent claims that the Complainant’s failure to enroll in 医疗保险B部分 is cause for denying the reimbursement of the Part D premium paid by the Complainant. 第三条A. (10)(d) of the 雇主 benefit Plan states that the benefits provided under the Plan will not be paid to a beneficiary otherwise eligible unless the beneficiary is enrolled in each part of 医疗保险 for which he is eligible.

在ROD 02-029, 雇主要求其符合医疗保险资格的受益人参加医疗保险A部分, B和D保留其在雇主福利计划下的健康福利. 先前的rod明确规定雇主可以要求其受益人参加医疗保险A部分, 除非需要额外费用, 和医疗保险B部分, 如果他们两个都有资格, 根据雇主福利计划保留其健康福利(见第88-659条), 88-644, 88-205, 和84 - 516年). 最终, the Trustees deadlocked on the issue of whether an 雇主 could require its beneficiaries to enroll in 医疗保险 Part D to retain their health benefits. 仲裁员采纳了雇主要求其受益人参加的意见, 由受益人自己承担费用, in 医疗保险 Part D is a violation of the 雇主 Benefit Plan and the National Bituminous Coal Wage Agreement.

原告, 一个老年人, 2006年3月，当他第一次获得医保B部分的资格时，他没有注册, 因为已获得社会保障残疾保险福利. 然而，申诉人确实在2006年4月参加了医疗保险D部分. 在随后的开放登记期间，他参加了医疗保险B部分, 该覆盖范围于7月1日生效, 2008.

Complainant seeks reimbursement of the 医疗保险 Part D premiums he paid during the time he was eligible for, 但没有注册, 医疗保险B部分, 并声称他不知道他必须参加医疗保险B部分. 第三条. A.(10)(d)2. of the 雇主 Benefit Plan provides that the Plan Administrator shall give written notification of a Beneficiary’s obligation to enroll in each part of 医疗保险 for which he is eligible. The Respondent contends that it sent a notice to Complainant informing him of the obligation to enroll in 医疗保险 to retain eligibility under the 雇主 Benefit Plan. The Trustees note that while the 雇主 Benefit Plan contains a requirement that the 雇主 notify in writing a 医疗保险-eligible beneficiary of the obligation to enroll in 医疗保险, the 雇主 Benefit Plan clearly states that failure to provide such notification does not remove the beneficiary’s obligation to enroll in 医疗保险A部分 & B. In RODs 84-516 and 84-679 the 养老金领取者s’ stated reasons for failing to enroll in B部分 were that they were not notified by the 雇主s of the 医疗保险 enrollment requirement. 这两种情况, the Trustees concluded that the 雇主s were not required to provide health benefits for the Complainants during the period when the Complainants were eligible for, 但没有按照雇主福利计划的要求参加医疗保险B部分.

投诉人从1974年养老金信托皇冠搏彩中心网站领取55岁养老金. 他获得了医疗保险A部分的资格 & B于2006年3月登记，但根据他最初的资格未能登记参加B部. 而ROD 02-029认为雇主要求受益人注册, 由受益人自己承担费用, in 医疗保险 Part D is a violation of the 雇主 Benefit Plan and the National Bituminous Coal Wage Agreement, 第三条.A. (10)(d)1. of the 雇主 Benefit Plan clearly states that an 雇主 is not required to provide health benefits for 一个老年人 who is eligible for, 但没有注册, 医疗保险A部分 & B. 因为投诉人在第一次获得资格时没有参加医疗保险B部分, 登记的生效日期是7月1日, 2008, 答辩人自3月1日起不负责支付医疗保险, 2006年至6月30日, 2008. The Respondent is not responsible for reimbursement of the 医疗保险 Part D premiums Complainant paid over this same time period because prescription drug coverage is a benefit payable under the 雇主 Benefit Plan and Complainant was not eligible for such coverage during the period that he was eligible for, 但没有注册, 医疗保险B部分.

受托人的意见

The Respondent is not required to reimburse the Complainant for the premiums Complainant paid to receive 医疗保险 Part D coverage during the period the Complainant was eligible for, 但没有报名参加, 医疗保险B部分.