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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:88-302 - 1991年9月24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 计划
and Trust, and 下 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 Employee 下 terms of the 雇主 Benefit
计划.
背景事实
原告 worked in a classified position for the Respondent from July 20, 1989 until he
是在1990年6月12日被解雇的. 申诉人随后接受了其他工作.
原告 has stated that when he began working for the Respondent, the Respondent
通过蓝十字和蓝盾提供健康保险.
原告 has submitted copies of unpaid bills incurred by his spouse for medical
services rendered on December 4 and 5, 1989 and during her hospitalization from December 15,
1989年至1990年1月5日. 在她入院时，医院工作人员联系了Blue
Cross and Blue Shield and were advised that coverage provided by the Respondent through that
开利是有效的. The hospital submitted claims to that carrier; however, the Complainant
was notified by the carrier in 1990年1月 that the claims would not be paid because his
服务日期前已取消承保范围. 申诉人认为
Respondent failed to maintain coverage as required by the Wage Agreement and is required to
支付他未付的医药费.
原告 has stated that the Respondent provided coverage through HealthAmerica, a
health maintenance organization (HMO), sometime after his coverage through Blue Cross and
蓝盾被终止了. 申诉人说，他没有选择HMO的保险
in lieu of 雇主 计划 coverage, and he does not know when this change in coverage was
使. 原告 has submitted a copy of a form letter he received from HealthAmerica
thanking him for subscribing to the HMO and enclosing identification cards for himself and each
受托人的意见
争议的解决
情况下没有. 88-302
第二页
他的家人. 信函未注明日期，申诉人说他没有
更有身份证. 申诉人说，收到了这一资料
在1990年1月的某个时候. 申诉人说，在他收到这些卡片后不久，
他被告知，该报道也已终止.
Information provided to the Funds by Blue Cross and Blue Shield indicates that coverage
provided by the Respondent through that carrier was only in effect for the month of August
1989. Information provided by HealthAmerica indicates that the Complainant was enrolled in
the HMO under a group plan paid for by the Respondent from October 1, 1989 through January
31, 1990. 向皇冠搏彩中心网站提供的其他信息表明被投诉人
subsequently provided coverage through a third party claims administrator; however, this
arrangement was terminated July 1, 1990 due to the Respondent’s non-payment of claims and
行政费用.
争端
Whether the Respondent is responsible for payment of the Complainant’s unpaid medical bills.
双方立场
Position of the Complainant: The Respondent is responsible for payment of the Complainant’s
medical bills because those bills are unpaid due to the Respondent’s failure to maintain the
申诉人的医疗保险.
Position of the Respondent: The Respondent has not replied to repeated correspondence from
皇冠搏彩中心网站工作人员请求其在这一争端中的立场.
相关的规定
Article XX (c)(3)(i) of the National Bituminous Coal Wage Agreement of 1988 provides in
相关的部分:
(3)(i)每一签署方雇主应设立并维持一名雇员
提供的福利计划, 通过保险公司实施, health and other nonpension benefits for its 员工 covered by this Agreement as well as pensioners, 下
1974 Pension 计划 and Trust, whose last signatory classified employment was with such
雇主. 雇主根据上述规定向其合格参与人提供的福利
plans shall be guaranteed during the term of this Agreement by that 雇主 at levels set forth
在这样的计划中…….
雇主福利计划第I(1)、(2)、(4)条规定:
第一条-定义
受托人的意见
争议的解决
情况下没有. 88-302
第3页
下列术语具有本协议规定的含义:
(1)“雇主”指(雇主名称).
(2)“工资协议”指全国烟煤工资
不时修订的1988年协议及任何后续协议
协议.
(4)“雇员”是指为公司从事保密工作的人员
雇主，有资格获得本协议项下的福利.
第二条A款. (4)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:
A. 积极的员工
(4)新员工从第一天起就有资格享受健康福利
与雇主合作.
第三条A. (10) (a)雇主福利计划的相关部分规定:
第三条-福利
A. 健康的好处
(10)总则
(a)卫生组织选举
第II条A、B、C和E款所述的任何受益人
可否选择经认证的健康保养机构承保
(HMO)代替本计划提供的健康福利
符合联邦或州管理HMO的法律;
但是，一个家庭的所有受益人应是
由卫生组织选举管理.
讨论
Article XX Section (c)(3)(i) of the 1988 Wage Agreement requires an 雇主 to establish and
maintain an 雇主福利计划 to provide health and other non-pension benefits for it
员工. 《皇冠搏彩中心》规定，雇主根据下列规定提供的福利
受托人的意见
争议的解决
情况下没有. 88-302
第4页
such 计划 shall be guaranteed during the term of the Agreement by that 雇主 at levels set
在该图则中列明.
第二条A款. (4)雇主福利计划为在职人员提供健康福利
为签约雇主从事机密工作的雇员. 因为申诉人
was actively employed in a classified position by the Respondent from July 20, 1989 until he
was laid-off in June 1990, the Respondent is required to provide health benefits coverage for the
投诉人及其合资格的家属在此期间.
第三条A. 雇主福利计划第(10)(a)条规定雇员可选择
coverage by an HMO in lieu of the health benefits provided under 雇主福利计划,
一个家庭的所有受益人都应受卫生组织选举的管辖. 原告
in this case has unpaid medical bills which were incurred by his spouse in December 1989 and
1990年1月. 虽然被告显然是通过HMO在
time the Complainant’s bills were incurred, the Complainant states that he did not elect such
coverage in lieu of the health benefits provided under 雇主福利计划, that he had not
been notified of such coverage when the bills were incurred, and that his coverage through Blue
Cross and Blue Shield had been confirmed by the provider at the time the bills were incurred.
The Respondent has not responded to repeated requests for information concerning this dispute.
Absent evidence that this HMO coverage was offered by the Respondent and elected by the
Complainant in lieu of the benefits provided under 雇主福利计划, the Respondent is
responsible for payment of the covered medical expenses incurred by the Complainant and his
eligible dependents during December 1989 and 1990年1月, consistent with the terms of the
雇主福利计划.
受托人的意见
没有证据表明HMO的保险是由被告提供的，并由选民选择
Complainant in lieu of the benefits provided under 雇主福利计划, the Respondent is
responsible for payment of the 计划-covered medical expenses incurred by the Complainant and
his eligible dependents during December 1989 and 1990年1月, consistent with the terms of
雇主福利计划.