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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 Case No: 28 – 一九七九年十月十七日

Board of Trustees: Harrison Combs, Chairman; John J. 奥康奈尔,受托人;
Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute about the payment mechanism for health benefits provided to an Employee by an 雇主 and hereby render their opinion on the matter.

背景事实

Complainant (Board Member) represents active miners who are covered under 雇主’s Health Plan. Medical coverage as provided by 雇主’s Health Plan is not being accepted by local providers, thereby requiring miners to pay full provider’s fees, 而不是适用的共同支付 对于医生服务.

问题或争议

Employee has requested that the 雇主 be directed to alter its Health Plan in such as way as to ensure the acceptance of 雇主’s Health Plan by local providers as the responsible payor, 但对于适用的共付额, 对于医生服务. The 雇主 has responded that it is not the responsibility of the 雇主 to bind third parties (i.e., providers) to an agreement between the Settlors of the National Bituminous Coal Wage Agreement of 1978.

各方立场

Claimant’s Position: 雇主’s 健康的好处 Plan is not in compliance with the provisions of the National Bituminous Coal Wage Agreement of 1978 in that Employees are being required to make payments in full 对于医生服务, 而不是适用的共同支付. This is due to the fact that local providers are refusing to accept the 雇主’s Health Plan coverage. 雇主 is responsible for providing to Employee a Health Benefit Plan which is acceptable to local physicians.

雇主’s Position: An Employee can pay only the $7.50 copayment charge to a physician rendering a medical procedure which is covered under the 雇主’s Plan. In those cases where providers have selected not to cooperate with the intent of the Plan provisions, it is not the responsibility of the 雇主 to bind providers to an agreement between the Settlors of the National Bituminous Coal Wage Agreement of 1978.

国家有关规定

Article XX, (10)(g) provides as follows:

“Benefits for office visits to physicians, 医生上门服务, 在医院的医疗护理, visits to a clinic or the out-patient department of a hospital will be subject to a $7.每次50元 copayment in the case of working miners and their dependents up to an annual maximum of $150 per family.

Explanatory Note on 雇主 Provided Health Plans of National Bituminous Coal Wage Agreement, 第二十条第(十)款规定如下:

“All benefits will be at the level of benefits provided by the 1974 Benefit Plan prior to July 1, 1977 except for the following copayments by the patient:

工作的矿工

处方药$5.每张处方00美元
医生收费7美元.每次50元

“. . . 在某些情况下, when the Employee pays for services or drugs, the bills should be obtained and submitted with the claim form according to the instructions on the form. If, the annual copayment maximum has been reached, the carrier will remit to the Participant the full payment for covered benefits.”

Article III, Section A(8) of the 雇主’s Benefit Plan described copayment benefits. Nowhere in this provision is there an indication that the Plan Administrator is responsible for assuring acceptance by providers of the 雇主’s Health Plan.

讨论

Nothing in the National Bituminous Coal Wage Agreement of 1978 or in the provisions of the 雇主’s health plan obligates the company or its designated carriers to assure acceptance of coverage by health care providers. The fact that providers in some areas choose not to honor the company plan for payment of covered services does not prevent the covered employee or his/her eligible dependents from obtaining the contractually bargained benefits.

The copayment provision speaks only to the family’s annual copayment obligation and not to mechanisms of payment. There is no stated prohibition against the beneficiary incurring the liability and then seeking reimbursement for all covered costs.

受托人的意见

The Trustees are of the opinion that the 雇主 has no obligation to assure that health care providers accept the 雇主’s health plan as the responsible payor, 但对于适用的共付额.