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OPINION OF TRUSTEES
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In Re

Complainant: Employees
Respondent: Employer
ROD Case No: 88-633 – August 5, 1993

Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.

受托人审查了有关根据雇主福利计划及时支付雇员健康索赔的争议的事实和情况.

Background Facts

The Complainants are Employees who are covered under a health benefits plan provided by the Respondent. 申诉人认为，被申请人未能按照1988年《皇冠搏彩中心》("工资协定")第二十条的规定及时支付健康索赔. 雇员声明，由于雇主未能在合理的时间内支付医疗福利，他们的信用等级已处于危险之中. The Complainants have included copies of bills that had been outstanding for up to six months. In some cases, providers have added interest charges on unpaid balances resulting in additional costs.

The Respondent provides health benefits coverage for the Complainants through a third party claims administrator, Northwest National Life Insurance Company, which processes and pays the claims from funds provided by the Respondent. The Respondent does not deny that it is behind in paying claims that have been submitted, but states that the delays are due to cash flow problems beyond its control. The Respondent contends that every attempt is being made to catch up as quickly as possible, but if forced to pay all medical claims at one time, the company would have to cut drastically in some other area, possibly trading jobs for benefits. 被投诉人进一步指出，面临实际诉讼或强制收款威胁的雇员已被指示提请雇主注意这一点，以便能够首先支付这些特定的索赔. In some cases, the Respondent has contacted providers to inform them that payment will be made as soon as possible.

The Employer contends that its financial situation is improving and that with cooperation and patience, all of the claims will eventually be resolved.

Dispute

被投诉人是否按照《皇冠搏彩中心》第20条的规定为投诉人及其符合条件的受抚养人提供医疗保险.

Positions of the Parties

申诉人的立场:被投诉人未能及时为申诉人提供医疗保险. 投诉人须及时支付投诉人及其合资格受养人的医疗费用.

答辩人的立场:答辩人正在尽最大努力为其雇员和符合条件的家属提供健康福利，因为其现金流问题是由于超出其控制的情况造成的，应允许答辩人有时间支付未偿的医疗索赔，以便公司能够继续经营并继续向工会成员提供工作.

Pertinent Provisions

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

(3)(i) Each signatory Employer shall establish and maintain an Employee benefit plan to provide, implemented through an insurance carrier(s), health and other non-pension benefits for its Employees covered by this Agreement as well as pensioners, under the 1974 Pension Plan and Trust, whose last signatory classified employment was with such Employer. 在本协议有效期内，雇主根据该等计划向其合格参与人提供的福利应按该等计划中规定的水平予以保证。.

Article XX, General Description, Section (12) Health Care Cost Containment, states in pertinent part:

The Union and the Employers recognize the rapidly escalating health care costs, including the costs of medically unnecessary services and inappropriate treatment, have a detrimental impact on the health benefit program. The Union and the Employers agree that a solution to this mutual problem requires the cooperation of both parties, at all levels, to control costs and to work with the health care community to provide quality health care at reasonable costs. The Union and the Employers are, therefore, committed to fully support appropriate programs designed to accomplish this objective. 这一目的声明绝不意味着减少矿工所提供服务的福利或增加费用, pensioners and their families….

Discussion

Article XX, 《皇冠搏彩中心》第(c)(3)(i)条规定，雇主必须为本协议所涵盖的员工建立并维持员工福利计划. 《皇冠搏彩中心》和《皇冠搏彩中心》都没有规定雇主必须在多长时间内履行其提供健康福利的合同义务. 及时支付受益人健康索赔的问题先前已在第88-492号法规中解决(随函附上副本)。. In that opinion, the Trustees stated that the Employer’s failure to process health benefit claims in a timely manner did not conform to the requirements of the Wage Agreement or the Plan; that processing time should not cause collection action to be taken against the Complainants nor result in any actions that would impair their creditworthiness; that the Employer must insulate and defend the complainants against any such actions.

被投诉人还辩称，由于财政问题，它无法更及时地支付投诉人的福利索偿. In RODs 84-360 and 84-582, 受托人的结论是，雇主糟糕的财务状况不能作为要求获得合同规定的福利的有效辩护.

As noted in ROD 88-492 (attached), 行业惯例和大多数州规定的期限要求表明，处理和支付清洁索赔的合理范围是15至60天. 随本案提交的资料表明，雇主允许未处理的健康索赔长达7个月. Given industry practice and the fact that Complainants have been threatened with collection actions, 受托人的结论是，答辩人支付申诉人医疗索赔的期限不合理. 答辩人已建议受到诉讼和强制催收威胁的雇员与答辩人联系，以便首先支付这些索赔，而且答辩人已代表雇员打电话给供应商，这一事实并不能减轻答辩人及时处理和支付健康福利索赔的责任. 雇主只有在雇员受到供应商采取催收行动的威胁且其信用评级受到损害后，才会采取这些行动.

Additionally, pursuant to Article XX, the General Description, Section (12) of the NBCWA, no reduction of benefits or additional costs for covered services shall be suffered by beneficiaries.

Opinion of the Trustees

雇主未能及时处理申诉人的健康福利要求，不符合1988年《皇冠搏彩中心》或雇主福利计划的要求. 雇主或其代理人为裁决医疗福利索赔所花费的处理时间不得导致对投诉人采取催收行动，也不得导致损害投诉人信誉的任何其他行动. The Employer must insulate and defend the Complainants against any such actions initiated by the providers.