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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 81-575——1985年4月29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 an 员工 under the terms of the 雇主 Benefit Plan. 他们在此就此事发表意见.

背景事实

The Complainant performed classified work for the Respondent from July 1977 through December 1984. 1979年12月, he injured his back on the job and reported the injury to the Respondent, as well as to its worker’s compensation insurance carrier. Neither party has submitted any evidence that 原告 actually received a worker’s compensation award or agreed to a settlement of a worker’s compensation claim that might have excluded payment for future medical expenses arising from the December 1979 injury. The Complainant reported no further problems with this injury until July 1984, when he was admitted to the hospital for medical treatment. He filed his medical claims with the worker’s compensation carriers. 根据答辩人, the claims were denied due to a Virginia statute of limitations of two years on an injury recurrence claim. The Complainant subsequently filed the claims with the Respondent’s health insurance carrier. 付款 of these claims was denied “because the injury was work related.”

The Complainant believes that he was eligible for health benefits coverage at the time of his hospitalization, and that the Respondent should be responsible for payment of his medical bills. The Respondent maintains that it is not responsible for payment of these bills because both its worker’s compensation carrier and hospital insurance carrier have denied the claim for legitimate reasons.

争端

Is the Respondent responsible for payment of 原告’s medical bills incurred in July 1984 for treatment to his back?

各方立场

Position of 原告: The Respondent is responsible for provision of health benefits coverage to 原告 and should pay medical bills incurred in July 1984.

Position of the 被申请人: The Respondent is not responsible for payment of the medical bills in question because its worker’s compensation carrier rightfully denied coverage under the statute of limitations and its medical insurance carrier legitimately denied the claim under the general exclusion pertaining to cases covered by worker’s compensation laws.

相关的规定

Article I (1) (2) and (4) of the 雇主 Benefit Plan provides:

第一条-定义

The following terms shall have the meanings herein set forth:

1. “雇主”指(煤炭公司).

2. “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1981, 如不时修订及任何后续协议.

4. “员工” shall mean a person working in a classified job for the 雇主, 有资格获得本协议项下的福利.

雇主福利计划第二条A款规定:

第二条-资格

The persons eligible to receive the health benefits pursuant to Article III are as follows:

A. 积极的员工

Benefits under Article III shall be provided to any 员工 who:

(1) is actively at work* for the 雇主 on the effective date of the Wage Agreement; or…

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*”Actively at work” includes an 员工 of the 雇主 who was actively at work on March 26, 1981, and who returns to active work with the 雇主 within two weeks after the effective date of the Wage Agreement.

Article III A (11) (a) (1) of the 雇主 Benefit Plan provides:

第三条-福利

A. 健康的好处

(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:

1. Cases covered by workers’ compensation laws or employer’s liability acts or services for which an employer is required by law to furnish in whole or in part.

讨论

根据雇主福利计划第II A(1)条, 原告, 积极的雇员, is eligible for health benefits coverage by the Respondent. Article III A (11) of the Plan outlines general exclusions, one of which is “cases covered by worker’s compensation laws or 雇主’s liability acts or services which an 雇主 is required by law to furnish in whole or in part.“然而, there is no evidence that 原告 received a worker’s compensation award or agreed to settle a worker’s compensation claim.

As 原告’s July 1984 medical treatment for his back did not meet the criteria for consideration as a workers’ compensation case because the two year statute of limitations had expired, the Trustees find that it cannot be considered a “case covered by worker’s compensation” within the meaning of Article III A (11). The Trustees therefore conclude that the Respondent is responsible for payment of medical bills incurred by 原告 in July 1984.

受托人的意见

The Respondent is responsible for payment of 原告’s medical bills incurred in July 1984.