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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: 88-694 - 1995年5月3日

受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德森和罗伯特·T. 华莱士.

受托人审查了有关根据雇主福利计划为领取工人补偿福利的雇员提供健康福利的争议的事实和情况.

背景事实

The 员工 was an active employee of the 雇主 for 11 years until 3月5日, 1992, 当他因工伤而停止工作时，他目前正在领取工人赔偿福利. 雇员表示，根据其11年的服务，他应该有资格享受为期12个月的延长医疗福利, 或截止到3月31日, 1993. 另外, the 员工 submitted several bills that were denied by the 雇主’s claims administrator, 总计626美元.17, for services rendered to his spouse between July 25, 1992年和11月13日, 1992.

用人单位 states that the claims in question were used to recover an overpayment, 和 explains the sequence of events as follows: The 员工’s spouse incurred charges totalling $2,1月4日的服务费用为400英镑, 1991, 索赔管理人为此支付了1美元,100. 雇主支付了剩下的1美元,10月29日，300美元直接支付给供应商, 1991年作为“保持无害”的解决方案. 随后, 雇主的索赔管理人重新审查了案件，并直接向雇员支付了额外的805美元, since the provider was not a Blue Cross/Blue Shield participating provider.

雇主于12月16日通知雇员, 1991 that the $805 check had been sent in error 和 should be returned. The 员工 said he had not yet received the check, but would return it. 1月22日, 1992, the claims administrator told the 雇主 the $805 check had been cashed by the 员工 on December 10, 1991, 雇主来电前6天. 用人单位 contacted the 员工 immediately to make arrangements to recover the overpayment. 雇员说他已经花了钱, but was willing to have $50 deducted from each pay check until the $805 was recovered. The 员工 went on Workers Compensation on March 6, 1992 after re-paying $200 of the $805. 用人单位, unable under law to withhold from Workers Compensation benefits, asked the 员工 to repay $50 each payday by personal check. 用人单位 stated that this effort failed after several attempts, 及雇主, 6月19日, 1992, 指示其索赔管理人扣留该雇员配偶未来索赔的应付福利，直至偿还剩余的605美元. 12月11日, 1992, 索赔管理人说，605美元已被扣留，今后的福利金将恢复支付.

用人单位 states that the 员工 was provided with medical benefits from the last day worked, 3月5日, 1992, 到3月31日, 1993. 关于626美元.17 in charges for the 员工’s wife: $605 was withheld to satisfy the 员工’s remaining obligation, 剩下的21美元.17美元于1993年3月8日支付给雇员.

争端

雇主是否按照雇主福利计划第三条规定的水平向雇员提供健康福利? 雇主是否有权追讨雇员在7月25日期间为其妻子提供的服务而错误支付的福利款项, 1992年至11月13日, 1992年，金额为805美元?

双方立场

雇员的地位:雇主必须向雇员提供1992年3月剩余时间内的健康福利, 以及从3月5日开始的12个月, 1992年，一直持续到3月31日, 1993. 另外, the 雇主 is required to provide benefits for charges 总计626美元.17, for services provided to the 员工’s wife between July 25, 1992年和11月13日, 1992.
雇主职位:雇主为雇员提供自3月5日起12个月的医疗福利, 1992年，4月1日结束, 1993, based on his length of service with the 雇主 和 as provided in 第三条. D. (1)(b). 用人单位 has the right to recover overpayments from benefits due on other medical claims, after reasonable attempts are made to recover them in other ways.

相关的规定

Article XX Section (c)(3)(i) of the National Bituminous Coal Wage Agreement of 1988 provides, 在相关部分:

(3)(i) Each signatory 雇主 shall establish 和 maintain an 员工 benefit plan to provide, 通过保险公司实施, health 和 other non-pension benefits for its 员工s covered by this Agreement as well as pensioners, 1974年养恤金计划和信托皇冠搏彩中心网站, whose last signatory classified employment was with such 雇主….

Article I (1),(2),(6) 和 (9) of the 雇主 Benefit Plan provide:

第一条-定义

The following terms shall have the meanings herein set forth:
(1) “雇主”指(雇主名称).

(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1988, 如不时修订及任何后续协议.

(6)“受益人”系指根据本计划有资格获得本协议第三条规定的健康福利的任何人.

(9) “签字服务”应与美国联合煤矿工人1974年养老金计划(“1974年养老金计划”)或其任何后续计划中赋予该术语的含义相同.

第二条乙. (1)雇主福利计划规定:

第2条资格

根据第二条A节第(1)和(2)款，有资格领取健康津贴的人员如下:

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; or

(2)被雇主解雇或残疾，并且在工资协议生效之日，作为被解雇或残疾的雇员，继续有资格享受1984年雇主福利计划(“先前计划”)的保险. 对这些下岗或残疾雇员的保险不得在其根据先前计划的规定不再有资格获得此类保险的日期之后继续提供.

第三条.D.(1) (a)、(b)、(d)说明:

(1)续保

(一)裁员

如果雇员因裁员而停止工作, 健康的延续, life 和 accidental death 和 dismemberment insurance coverage is as follows:

工作时数
24 .雇主
连续日历月
紧接前一时期 保险期限
雇员入职日期 继续
最后工作日期最后工作时间

每月结余2000小时或以上
12个月

500或以上但少于月结余额
2000小时 6个月

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, 身残时的人寿、意外死亡和肢解保险，以(i)有资格领取疾病和意外福利金的期间较长者为准, 或(ii)上述(a)项附表所列期间.

(d)最大限度地继续承保

In no event shall any combination of the provisions of (a), (b), (c), 上述(e)或(g)项的结果是，在该月余额加上自最后工作日期起计的12个月后，继续承保.

讨论

1988年全国烟煤工资协议(工资协议)第XX条(c)(3)(i)款要求签署雇主建立并维持雇主福利计划，为其在职雇员和退休人员提供健康和其他非养老金福利，其最后签署的分类就业是在该雇主. Article I defines a Beneficiary as any person who is eligible, 根据该计划, 领取第三条规定的健康津贴. 第二条.A.(2)在其对“在职员工”的定义中包含, 被雇主解雇或伤残的雇员, 和 had continuing eligibility as of the effective date of the 1988 雇主 Benefit Plan. 第三条.D.(1)(b)提供持续健康, 伤残雇员的生命和意外死亡及伤残津贴，以(i)有资格领取疾病和意外津贴的期间较长者为准, or (ii) the period set forth in the schedule in 第三条.D.(1)(a). Both parties agree on the 健康的延续 benefits coverage 到3月31日, 1993, 所以这件事没有争议.

剩余的问题涉及雇主使用抵销来收回错误支付给雇员的多付款项. The 员工 alleges that the 雇主 did not provide coverage from July 25, 1992年至11月13日, 1992 since only very limited benefits were provided for the charges of $626.17英镑是他妻子当时欠下的. 用人单位 states that coverage was maintained on behalf of the 员工 during this time, but that some benefits were withheld in order to recover an outst和ing overpayment.

如ROD 88-561所述(副本随附), 雇主福利计划中没有规定在存在超额付款时抵销利益. 然而, 如ROD 88-561所述, under Department of Labor opinion letters 和 other authorities, a welfare plan may use offset to recoup an erroneous payment to a participant or beneficiary, 前提是该计划的复苏是谨慎的. Whether recovery is prudent depends on the facts 和 circumstances in each case. 因此, 例如, 审慎的做法可能是，允许参与人按月偿还计划，或从每月分配给参与人的福利中抵消部分补偿金额，从而在定期付款的基础上收回资金. 在其他情况下, depending upon the hardship resulting to the participant from recoupment, 一项应用抵消的计划可能是轻率的. 雇主提供的资料表明，805美元多付款项中的605美元已通过抵消雇员配偶的健康福利而收回, after the initial $50-per-paycheck withholding ended with the Workers Compensation-related injury. This amount 和 the procedure used to offset are not disputed by the 员工.

这种健康福利抵消的安排是否谨慎? 根据记录, the 雇主 made reasonable efforts to recover the overpayment from the 员工, 从每支工资50美元的扣缴开始, 雇员同意的. 然而, 只还了200美元, 雇员受伤, 停止工作, 和 is currently on disability 和 receiving Workers Compensation Benefits. 用人单位 could not legally withhold funds from Workers Compensation benefits, 和 requested that the 员工 repay $50 by personal check every payday. 这一努力在几次尝试后失败，雇主随后授权其索赔管理人从应付给雇员的健康福利中扣除雇员配偶产生的费用. 索赔管理人扣留了626美元.17从雇员配偶的费用中扣除, 并于七月二十五日之间发生, 1992年和11月13日, 1992. When the overpayment was satisfied, benefits payments were resumed 及雇主 paid $21.17 to the 员工 on March 8, 1993 for the balance of the $626.17日费用.

受托人认为，在这种情况下，雇主采取了谨慎的行动，在一段时间内多次努力以小额付款的方式向雇员追回多付的款项, 和, 考虑到涉及的金额相对较小, 在没有其他补偿办法的情况下，在6个月内从雇员的健康福利中扣缴605美元. 进一步, 数额没有争议是有关系的, 不是实质性的，雇员没有证明他因抵消而遭受了不适当的困难. 如前所述，

将健康福利覆盖范围延续至3月31日, 1993年在这种情况下不是问题, 因为双方都同意这个期限.

受托人的意见

在这种情况下，雇主采取了谨慎的行动，最初扣缴了50美元的工资，并在一段时间内多次努力向雇员追回无可争议的多付款项, 和 considering the amount involved 和 no showing of undue hardship, in withholding the $605 from the 员工’s spouse’s health benefits over a six month period.