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受托人的意见
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在再保险
原告: 残疾员工
被申请人: 雇主
ROD案例编号: 84-190——1986年7月28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”) 1980 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 benefits coverage for a disabled Employee under the terms 雇主福利计划的成员.
背景事实
The Complainant performed classified work for the Respondent from November 3, 1969年至11月17日, 1984 when he suffered a cerebral hemorrhage as the result of an aneurysm. 根据皇冠搏彩中心网站组织的记录, 投诉人工作了2年,862 hours for the Respondent during the 24-month period immediately prior to his date last worked. Because of his physical condition, the Complainant was unable to return to work until April 2, 1986.
The Respondent states that it provided continued health benefits coverage for the Complainant from November 17, 1984年至11月30日, 1985. The Complainant was eligible for Sickness and Accident benefits for a period of 52 weeks. 申诉人于4月2日返回工作岗位时, 1986, his benefits were reinstated as an active Employee.
The union representative for the Complainant asks that the Respondent be found responsible for coverage of all medical services relative to the Complainant’s aneurysm and cerebral hemorrhage, regardless of the dates such services are rendered.
争端
Is the Respondent responsible for providing health benefits coverage relative to the Complainant’s disabling condition beyond November 30, 1985?
各方立场
Position of the Complainant’s Representative: The Respondent is responsible for providing coverage for all medical services relative to the Complainant’s aneurysm and cerebral hemorrhage.
Position of the 被申请人: The Respondent is only responsible for providing continued benefits coverage for the Complainant from November 17, 1984年至11月30日, 1988.
相关的规定
Article I (1),(2) and (4) 雇主福利计划的成员 provides:
第一条-定义
The following terms shall have the meanings herein set forth:
(1) “雇主”指(煤炭公司名称).
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1984, as amended from time to time and any successor agreement.
(4) “Employee” 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.
第二条丙. (3)雇主福利计划规定:
第二条-资格
The persons eligible to receive the health benefits pursuant to Article III are as follows:
C. 残疾员工
In addition to disabled Pensioners who are receiving pension benefits and are therefore entitled to receive health benefits under paragraph B of this Article II, health benefits under Article III shall also be provided to any Employee who:
(3) 是接收还是会接收?, 正确应用后, be eligible to receive Sickness and Accident Benefits pursuant to the Wage Agreement.
Life and accidental death and dismemberment insurance shall also be provided to Employees described in (3) above.
第三条A. (11)(a) (2)(ii)及D. (1)(a),(b) and (d) 雇主福利计划的成员 provide:
第三条-福利
A. 健康的好处
(11)一般除外条款
(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:
2. 提供的服务
(ii) subsequent to the period after which a Beneficiary is no longer eligible for benefits under the Plan;
D. 一般规定
(1) 续保
(a) 裁员
如果雇员因裁员而停止工作, 健康的延续, life and accidental death and dismemberment insurance coverage is as follows:
工作小时数
连续24年的雇主
日历月期间
在雇员的最后日期之前 续保期
工作 从上次工作日期开始
2000小时以上 月余额加上12个月
500或更多，但少于 月余额加上6个月2000小时
少于500小时 30天
(b) 残疾
第二条另有规定的除外, 部分C, 雇员因残疾而停止工作, 雇员将有资格继续保持健康, life and accidental death and dismemberment coverage while disabled for the greater of (i) the period of eligibility for Sickness and Accident benefits, or (ii) the period as set forth in the schedule in (a) above.
(d) 最大续保范围
In no event shall any combination of the provisions of (a), (b), (c), (e) or (g) above result in continuation of coverage beyond the balance of the month plus 12 months from the date last worked.
讨论
根据第三条D款. 雇主福利计划的成员, the 雇主 is required to provide continued health benefits coverage to a disabled Employee for the greater of his period of eligibility for Sickness and Accident benefits or his period of eligibility based on the number of hours worked during the 24-month period prior to his date last worked. 皇冠搏彩中心网站的记录显示投诉人工作了2年,862 hours for the Respondent during the 24 consecutive calendar months prior to the onset of his disabling condition on November 17, 1984. 相应的, the Respondent is responsible for the 健康的延续 benefits coverage for the Complainant through November 30, 1985, 第三条D款所允许的最长期限.
第三条A. (11) 雇主福利计划的成员 specifically excludes coverage for services rendered subsequent to the termination of an Employee’s period of eligibility for benefits under the Plan. 因此, the Respondent is not responsible for providing continuation of coverage for services rendered after November 30, 1988.
受托人的意见
The Respondent is responsible for the provision of health benefits coverage for the Complainant through November 30, 1988. The Respondent is not responsible for providing continued coverage for any services rendered to the Complainant between November 30, 1985年，他恢复了正式员工的身份.