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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: 88-425 - 1991年10月31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.

根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits coverage for a 养老金领取者 under the terms of the 雇主 Benefit Plan.

背景事实

申诉人于1985年5月10日在为答辩人从事机密工作时受伤. 因为他受伤了, 他无法重返工作岗位，并获得了工人赔偿. 1988年10月, the Complainant applied for Social Security Disability Insurance (“SSDI”) benefits under Title II of the Social Security Act. 1989年12月, his application was approved on appeal by an Administrative Law Judge with a disability onset date of May 10, 1985.

2月13日, 1990, 投诉人根据1974年UMWA养恤金计划提出养恤金福利申请. 投诉人收到日期为9月14日的信函通知, 1990年，他获得了1974年养老金计划最低残疾养老金, 追溯至六月一日, 1985. 投诉人被建议与被投诉人联系, 他最后一个签字的雇主, 关于他作为养恤金领取者享受健康福利的资格. 申诉人说，被投诉人拒绝向他提供医疗保险.

根据答辩人, 申诉人在为前雇主工作时受伤, although the Complainant claims the prior injury was aggravated by an accident that occurred while working for the Respondent, 这次事故没有目击者. The Respondent states that the Complainant drove himself home the day such accident allegedly occurred and failed to-return to work thereafter. The Respondent claims that another 雇主 may be responsible for providing the Complainant’s health benefits coverage because the Respondent does not believe that the Complainant was injured while employed with the Respondent.

The Respondent also contends that if the Trustees determine that it is responsible for providing the Complainant’s coverage, 不应要求其在受托人作出决定之日之前提供保险.

争端

雇主是否需要为投诉人提供医疗保险?

双方立场

Position of the 原告: The Respondent is required to provide health benefits coverage for the Complainant 6月1日生效, 1985.

Position of the 被申请人: The Respondent is not required to provide health benefits coverage for the Complainant as a disability 养老金领取者 because the Complainant was injured while working in a classified job for a previous 雇主. 然而, 如果受托人确定被投诉人需要为投诉人提供保险, the Respondent should not be required to provide coverage prior to the date of the Trustees’ decision because the Wage Agreement does not specifically provide for retroactive payments and the Respondent should not have to pay expenses for which documentation may no longer be available.

相关的规定

Article XX Section (c)(3)(i) of the National Bituminous Coal Wage Agreements of 1984 and 1988 provides in pertinent part:

(3)(i) 每一签署雇主应建立并维持雇员福利计划，以提供, 通过保险公司实施, 本协议所涵盖的雇员以及领取养老金者的健康和其他非养老金福利, 1974年养恤金计划和信托皇冠搏彩中心网站, 谁的最后一个签署人曾受雇于该雇主. The benefits provided by the 雇主 to its eligible Participants pursuant to such plans shall be guaranteed during the term of this Agreement by that 雇主 at levels set forth in such plans…. The plans established pursuant to this subsection are incorporated by reference and made a part of this Agreement, and the terms and conditions under which the health and other non-pension benefits will be provided under such plans are as to be set forth in such plans.

1984年和1988年雇主福利计划第1(1)、(2)和(5)条规定:

第一条-定义

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”系指1984年[1988]《皇冠搏彩中心》。, 如不时修订及任何后续协议.

(5) “养恤金领取者”系指领取养恤金的任何人, 除了(i)根据少于20年的记帐服务领取的递延既得退休金, or (ii) a pension based in whole or in part on years of service credited under the terms of Article II of the 1974 Pension Plan, 或其任何继承者的任何相应段落, 根据1974年退休金计划(或其任何后续计划), 谁的最后一次机密签署工作是在雇主处, 以本计划第二条B款的规定为准.

第二条乙. 1984年及1988年雇主福利计划第(1)条规定:

第二条-资格

根据第三条有资格领取健康津贴的人员如下:

B. 养老金领取者

根据本办法第三条向养恤金领取人提供的健康津贴和人寿保险如下:

(1) 任何退休金领取者，在

(a) 根据1974年养恤金计划领取养恤金者的最初退休日期;及

(b) 10月1日, 1984年2月1日, 1988], 都有资格作为养老金领取者享受以下的保险, 并受本计划所有其他条款的约束. 尽管本计划第i(5)条对退休金领取人的定义有(i)及(ii)项规定, any such 养老金领取者 who was eligible for benefits under the 1974 Benefit Plan as a 养老金领取者 on December 5, 1977, 都有资格享受这些福利, 受本计划所有其他条文规限.

讨论

Article XX of the 1984 and 1988 Wage Agreements requires a signatory 雇主 to establish and maintain an 雇主 Benefit Plan to provide health and other non-pensIon benefits for 养老金领取者 谁的最后一个签署人曾受雇于该雇主. 第二条乙. of the 雇主 Benefit Plan establishes that 养老金领取者 are entitled to the health benefits provided under such Plan. Article I (5) of the Plan defines such 养老金领取者 as any person 谁的最后一次机密签署工作是在雇主处, 根据1974年妇女事务部养恤金计划领取养恤金, 不包括以少于20年的记帐服务为基础的递延既得退休金, or a pension based in whole or in part on years of service credited under the terms of Article II of the 1974 Pension Plan.

本案投诉人领取1974年养恤金计划最低残疾养恤金, 6月1日生效, 1985. He is not receiving a deferred vested pension nor a pension based in whole or in part on years of service credited under the terms of Article II of the 1974 Pension Plan. Inasmuch as the Complainant is receiving a Minimum Disability pension and his last classified signatory employment was with the Respondent, 他是雇主福利计划第I(5)条定义下的养老金领取者, 并且有资格根据被投诉人制定的计划获得健康福利.

The Respondent claims that it should not be required to provide health benefits for the Complainant prior to the date of the Trustees’ decision in this case because the Wage Agreement does not provide for retroactive payments and it should not be required to pay expenses for which documentation may no longer be available. The issue of when an 雇主’s responsibility to provide health benefits coverage commences has previously been addressed by the Trustees. 在rod 78-343, 81-521, 84-437, 88-230及88-367(随函附上副本), the Trustees concluded than an individual satisfies the definition of “养老金领取者” as set forth in Article I (5) of the 雇主 Benefit Plan as of the effective date of his pension. 因此, the 雇主’s obligation to provide health benefits coverage commences as of the pension effective date. 本案的投诉人于6月1日起成为该计划第I(5)条所定义的养老金领取者, 1985. 因此, the Respondent is responsible for providing health benefits coverage for the Complainant and his eligible dependents from that date, 以及用于支付投诉人在6月1日之后发生的医疗费用, 1985, 只要提交文件证明费用包括在福利范围内.

受托人的意见

被投诉人负责为投诉人作为养恤金领取者提供医疗保险, 6月1日生效, 1985, and for payment of the covered medical expenses incurred after that date during the Complainant’s eligibility for coverage under the Plan.