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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个案编号:02-023 - 2006年4月19日
受托人:michael W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰,
艾略特一. 西格尔.
受托人 have reviewed the facts and circumstances of this dispute concerning the provision
雇主福利计划条款下的福利.
背景事实
的 Complainants include Employees who are currently employed by the Respondent and former
在被投诉人受雇期间产生医疗费用的雇员. 代表
for the Complainants claims that the Respondent has failed to pay health claims in a timely
manner as required by the terms of the National Bituminous Coal Wage Agreement and the
雇主福利计划. 因此，投诉人已收到催收通知书及
statements from providers threatening collection 未付账单未付时的诉讼.
On March 11, 2005, a Funds’ staff member spoke with the Respondent’s Plan Administrator,
who stated that Accordia was the Respondent’s insurance carrier through March 31, 2004. 的
Respondent then changed to Corporate 好处 from April 1, 2004 through September 30, 2004.
Allied 好处s Administration has been the insurance carrier since October 1, 2004. 在2月份
2005, the Plan Administrator stated that he received a large envelope of claims from Corporate
好处. 有些索赔要求已经支付，其他索赔要求是重复的. 他说他
informed the employees that if they had unpaid claims for services prior to October 2004, they
应该给他寄一份账单的复印件吗.
A representative for the Respondent submitted information indicating that many of the medical
最初在争端中提交的账单已经支付. 该代表还表示，他
is still checking on some of the bills submitted in connection with this dispute and will provide
核实责任或付款后立即提供补充资料. 有问题的法案
服务日期由2004年8月至2005年7月.
After the ROD was filed, the representative for the Complainants worked with the Plan
Administrator to sort through the unpaid claims in an attempt to settle the dispute. 根据
the Complainants’ representative, although the Respondent paid a number of outstanding claims
originally submitted, late payment of claims by the Respondent continues to be an on-going
受托人的意见
连杆箱编号. 02-023
第二页
员工的问题. 因此，该代表要求提出争端
交受托人审阅.
的 Respondent is signatory to a modified 2002 National Bituminous Coal Wage Agreement
(“2002年工资协议”)，生效日期为2003年1月1日至2006年12月31日. 这
Agreement provides health coverage under an 80/20 plan and requires Employees to pay a
每月从雇员工资总额中扣除的保费.
争端
Is the Respondent providing health 好处 coverage for the Complainants as required under the
全国烟煤工资协议和雇主福利计划条款?
双方立场
Position of the Complainants: 的 Respondent is not providing health coverage as required under
the 全国烟煤工资协议和雇主福利计划条款 because
the Complainants receive collection notices and statements from providers threatening collection
未付账单未付时的诉讼.
Position of the Respondent: 的 Respondent is providing health 好处 coverage for the
Complainants as required under the terms of the 雇主福利计划 and Wage Agreement.
纠纷中最初提交的许多医疗账单都已支付. 此外,
information submitted by the Complainants’ representative “was selective in an obvious attempt
to portray the Company [as] not making payment[s] or progress surrounding the medical bill
困境.”
相关的规定
Article XX (c)(3)(i) of the National Bituminous Coal Wage Agreement of 2002 provides in
相关的部分:
(3)(i)各签字雇主应设立并维持一项雇员福利
计划提供, 通过保险公司实施, health and other nonpension 好处 for its Employees covered by this Agreement as well as pensioners under
1974年养老金计划和信托，其最后签署人的机密工作是
这样的老板. 雇主向其合格参与人提供的福利
pursuant to such plans shall be guaranteed during the term of this Agreement by that
雇主在这些计划中规定的水平.
受托人的意见
连杆箱编号. 02-023
第3页
2002年雇主福利计划第I(1)、(2)及(4)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”指全国烟煤工资
不时修订的2002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. 2002年雇主福利计划第(5)条规定:
第二条-资格
的 persons eligible to receive the health 好处 pursuant to Article III are as follows:
A. 积极的员工
(5)新员工从第一天起就有资格享受健康福利
我为雇主工作了一天.
讨论
Article XX (c)(3)(i) of the 2002 Wage Agreement requires an Employer to provide an Employer
好处 Plan that is 通过保险公司实施 for health and other non-pension
好处. It further requires that “好处 provided by the Employer to its eligible Participants
pursuant to such plans shall be guaranteed during the term of this Agreement by that Employer at
这些计划中规定的水平.第二条. 2002年雇主福利计划A规定了医疗保健
好处 coverage to active employees working in classified jobs for a signatory Employer.
的 Complainants in this case have received collection notices because the Respondent has
未能及时支付申诉人的医药费. 尽管雇主
好处 Plan does not specify a time period for processing and payment of medical claims,
Department of Labor regulations require the payment of a clean claim—a claim that does not
需要在30天内处理更多信息. 例如，皇冠搏彩中心网站组织进行审查
受托人的意见
连杆箱编号. 02-023
第4页
seventy percent of claims within a four-day period and pays a reviewed claim within seven to ten
天. 90%的索赔要求在10天内得到审查.
In ROD 98-046, the Trustees addressed the issue of processing undisputed or clean claims in a
timely manner and found that the time taken by the Employer or its agent to process and pay
health benefit claims should not cause collection action to be taken against the beneficiary nor
result in any other action that would impair the creditworthiness of the beneficiary. 受托人
also noted that the Employer must insulate and defend the beneficiary against any such actions
由提供者发起.
受托人的意见
的 Respondent’s failure to process clean or undisputed health 好处 claims for the
Complainants in a timely manner does not conform to the requirements of the Department of
劳工、全国烟煤工资协议或雇主福利计划. 的
processing time taken by the Respondent or its agent to adjudicate undisputed health benefit
claims may not cause collection action to be taken against a Complainant nor result in any other
会损害投诉人信誉的行为. 被告必须隔离
并就提供商发起的任何此类行动为投诉人辩护.