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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: 88-737 - 1995年8月3日
受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德逊和
罗伯特T. 华莱士.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for the daughter of an 员工 under the terms of the 雇主 Benefit Plan.
背景事实
The Complainant is eligible for health benefits coverage from the Respondent as an active 员工. 申诉人的女儿, 谁的出生日期是六月十一日, 1970, 在四月接受了门诊手术, 1993. The Respondent has denied health benefits coverage for the Complainant’s daughter’s surgery.
争端
Is the Respondent required to provide health benefits coverage for the Complainant’s daughter’s surgery performed in April, 1993?
双方立场
Position of the 员工: The Respondent is required to provide health benefits coverage for the Complainant’s daughter surgery in April, 1993 because the Complainant’s daughter’s physician’s office contacted the Respondent’s insurance carrier and was told that the Complainant had coverage and that pre-approval of an out-patient surgery was not necessary.
Position of the 被申请人: The Respondent is not required to provide health benefits coverage for the Complainant’s daughter because at the time of her surgery she was 22 years of age and was not an eligible dependent of an 员工 according to 第二条 D. (2)员工福利计划. Nor is the Complainant’s daughter disabled as defined by 第二条 D. (5)雇主福利计划.
相关的规定
篇文章中,我. (1), (2), (4) and (7) of the 雇主 Benefit Plan provides:
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, as amended from time to time and any successor agreement.
(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 第二条 hereof.
第二条. D. (2) and (5)雇主福利计划 provides:
第二条-资格
D. 合格的家属
Health benefits under 第三条 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:
(2) Unmarried dependent children 合资格雇员的 or 养老金领取者 who have not attained age 22;
(5)受抚养子女(任何年龄), 合资格雇员的, 领取养老金者或配偶, who are mentally retarded or who become disabled prior to attaining age 22 and such disability is continuous and are either living in the same household with such employee or 养老金领取者 or are confined to an institution for care or treatment. Health benefits for such children will continue as long as a surviving parent is eligible for health benefits.
为本D段的目的, a person shall be considered dependent upon an eligible 员工, 领取退休金者或配偶(如该雇员), 领取养老金者或配偶 provides on a regular basis over one-half of the support to such person.
第三条. A. (11) (a) 2. (ii) of the 雇主 Benefit Plan provides:
第三条-福利
A. 健康的好处
(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
2. 提供的服务
…
(ii) subsequent to the period after which a Beneficiary is no longer eligible for benefits under the Plan;
讨论
根据第II条D款. (2)雇主福利计划, health benefits are provided to unmarried dependent children 合资格雇员的 who have not attained age 22. 第三条A. (11) of the 雇主 Benefit Plan specifically excludes coverage for services rendered subsequent to the termination of a beneficiary’s eligibility under the Plan. The Trustees have addressed the issue of an 雇主’s responsibility under the 雇主 Benefit Plan to provide coverage for a dependent. ROD 84-078(附件副本), the Trustees concluded that ” coverage ceases on the date the child of a eligible 员工 no longer satisfies the eligibility requirements as set forth in 第二条 D. (2)计划.” Inasmuch as the Complainant’s daughter attained age 22 on June 11, 1992, the Respondent is not required to provide coverage for the Complainant’s daughter for services rendered to her after June 11, 1992.
The Complainant states that the 医生tor’s secretary was told by the Respondent’s insurance company that the “[Complainant] had coverage and that pre-approval of out-patient surgery was not necessary.” While the Complainant may have been told that pre-approval of out-patient surgery was not required, there is no evidence that the Respondent’s insurance company advised him that his daughter was eligible for this procedure under the Plan. 相应的, the evidence does not support a finding that the Respondent is responsible for the claimed benefits. 见ROD 81-655.
根据第II条D款. (5)本计划的条款, health coverage is available for certain dependent children who become disabled prior to attaining age 22. 申诉人不抗辩, nor does the evidence in the record establish, 他的女儿有残疾.
受托人的意见
The Respondent is not required provide health benefits coverage for the Complainant’s daughter after she attained age 22 on June 11, 1992.