______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
在再保险
Complainant: Surviving Spouse Respondent: Employer
ROD Case No: 73 – 1980年1月16日
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; 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 concerning the provision of pregnancy benefits for the surviving spouse of an Employee and hereby render their opinion on the matter.
背景事实
The Employee began employment with an Employer signatory to the NBCWA of 1978 on 10月13日, 1978 and was employed at the time the Respondent Employer, 也是签字人, purchased the mine from the original Employer and assumed operation of the mine, 2月1日, 1979. The Employee was killed in a mining accident on March 14, 1979 while working for the Respondent Employer.
The Employee and his wife were covered by the benefit plan of the first Employer from 10月13日, 1978年，直到矿山被出售, 2月1日, 1979. The Respondent Employer provided coverage beginning 2月1日, 1979年4月30日, 1979 transferred the Employee’s surviving spouse to another coal company group insurance plan, advising that all employees had been laid off and group coverage was not possible for one person.
The Employee’s wife was pregnant at the time he began employment with the first Employer, 10月13日, 1978. 孩子于6月21日出生, 1979 and payment of maternity and obstetrical services has been denied by the insurer.
问题或争议
Is the Respondent Employer responsible for payment of the maternity and obstetrical services rendered the Employee’s wife in June, 1979?
双方立场
第2页
The representative of the surviving spouse has raised the question concerning coverage. The Employer’s insurer bases denial of coverage on paragraph (10) (e) of the General Description of Health and Retirement Benefits contained in Article XX of the NBCWA of 1978 which states that, 对于新员工, benefit will not be provided for pregnancies which occur prior to the first day of employment (This section also states: “All other benefits are covered”).
相关的规定
As provided in Article III A(1)(h) and III A(3)(c), the Employer’s benefit plan is not responsible for payment of the maternity and obstetrical services for the Employee’s surviving spouse as the pregnancy commenced prior to the date of the Beneficiary’s eligibility under the plan. 然而, under the terms of the Pregnancy Discrimination Act, plans which provide coverage for pre- existing conditions may not exclude coverage only for pre-existing pregnancies. There are no exclusions under the Employer’s plan for any conditions except pregnancy, which is outlined in Article III A(h) and III A(3)(c) referred to in the foregoing. 因此, coverage for pregnancies which existed prior to a Beneficiary’s becoming eligible under the Employer’s benefit plan must be provided if the Beneficiary is eligible at the time of delivery. 本法生效日期, as it affects the Employer health and benefit plans, 是4月29日, 1979; therefore, plans must provide benefits mandated by the Act for services rendered after that date. 在即时情况下, since the plan had no exclusions for conditions other than pregnancy and the services were rendered in June, 1979, after the effective date of the Act, it would appear that the Employer’s plan should provide coverage.
受托人的意见
受托人认为, the terms of the Employer’s benefit plan, 3月27日通过, 1978, do not require coverage for the maternity and obstetrical services received by the Employee’s surviving spouse. 然而, because the plan must conform to the provisions of the Pregnancy Discrimination Act of 1978, 提供这样的保险.