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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: 84-224 - 1986年10月29日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长，受托人. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
Pursuant to 篇文章中,我X 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 level of health benefits coverage for an 员工 under the terms of the 雇主 Benefit Plan.
背景事实
The Complainant was an 员工 of the Respondent from June 1983 to April 1986. The Complainant has submitted unpaid bills for dental services provided to his wife. 除了, the Complainant has submitted unpaid medical bills for a gynecological office visit and laboratory test provided to his wife on November 5, 1985. The Complainant also has submitted a bill for an office service charge incurred on January 31, 1986 for the writing of a prescription for the Complainant’s wife.
The Complainant claims that the Respondent failed to provide his health benefits coverage as an 员工 and is now responsible for the payment of his unpaid medical and dental bills. The Respondent has failed to respond to repeated correspondence from the Funds regarding its position in this dispute.
争端
Is the Respondent responsible for the payment of outstanding medical and dental bills incurred by the Complainant’s wife?
双方立场
Position of the 原告: The Respondent is responsible for the payment of the medical and dental bills incurred by the Complainant s wife.
Position of the 被申请人: The Respondent has failed to present its position in this dispute.
相关的规定
篇文章中,我. (1), (2), (4) and (7) of the 1984 雇主 Benefit Plan provide:
第一条-定义
下列术语具有本协议规定的含义:
(1) “雇主”指(煤炭公司名称).
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1984, 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.
(7) “Dependent” shall mean any person described in Section D of 篇文章中,我ll hereof.
第二条. A.(1) D.(1) 1984年雇主福利计划规定:
第二条-资格
The persons eligible to receive the health benefits pursuant to 第三条 are as follows:
A. 积极的员工
Benefits under 第三条 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;
D. 合格的家属
Health benefits under 篇文章中,我ll shall be provided to the following members of the family of any 员工, 养老金领取者, or disabled 员工 receiving health benefits pursuant to paragraphs A, B, 或本条第2款(C)项:
(1) A spouse who is living with or being supported by an eligible 员工 or 养老金领取者;,
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* Actively-at-work includes an 员工 of the 雇主 who was actively at work on September 30, 1984, and who returns to active work with the 雇主 two weeks after the effective date of the Wage Agreement.
第三条. A.(3)(h), (J) and (p) of the 雇主 Benefit Plan provide in pertinent part:
第三条-福利
A. 健康的好处
(3) 医生服务和其他主要关注
(h) 家庭、诊所和办公室访问
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, 如果由医生提供.
(j) 化验及x光
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for a diagnosis or treatment of a definite condition, 疾病或受伤.
(p) 未涵盖的服务
5. 开处方的费用.
讨论
The Complainant has submitted unpaid bills for dental services incurred by his wife, and claims that the Respondent is responsible for payment of these bills. Inasmuch as dental benefits are provided under Article XX-A of the Coal Wage Agreement, and the Trustees have authority to resolve disputes involving benefits established by Article XX only, the Trustees may not address disputes concerning dental plan benefits.
The Complainant also claims that the Respondent is responsible for payment of medical bills incurred by his wife on November 5, 1985年和1月31日, 1986. 第二条. A.(1) D.(1) of the 雇主 Benefit Plan require an 雇主 to provide health benefits under 第三条 to its 员工s and their eligible dependents. Inasmuch as the Complainant’s wife is an eligible dependent of an 员工, 根据第三条，她有权享受健康福利.
第三条.A.(3)(h) and (j) provide for benefits for services rendered by a physician for the treatment of illnesses and for laboratory tests when required for diagnosis or treatment of a definite condition or illness. 第三条.A.(3)(p) specifically states that charges for writing a prescription are not covered services. Inasmuch as the office visit and laboratory test provided to the Complainant’s wife on November 5, 1985年为承保服务, 答辩人负责支付这些费用.
由于1月31日发生的办公室服务费, 1986年是开处方的时候, 未涵盖的服务, the Respondent is not responsible for the payment of that charge.
受托人的意见
The Respondent is responsible for the payment of the medical bills incurred by the Complainant’s wife on November 5, 1985. The Respondent is not responsible for the payment of the bill for the writing of a prescription for the Complainant’s wife.