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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
连杆箱编号. 131, 1980年9月29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 vision benefits for an 员工’s dependent daughter and hereby render their opinion on the matter.

背景事实

Complainant is an active mine worker eligible for health benefits under the 雇主’s Plan. The 员工’s dependent daughter was examined by an ophthalmologist and received a new pair of glasses with tinted oversized single lenses. The total charge for these services was $123.50. The insurance company paid $34.00 according to the benefit schedule for frames and examinations and denied the remaining $89.50 as non-covered services. 随后, the insurance company allowed an additional $20,00 coverage for the single lenses when new evidence was submitted by the physician, 剩下69美元.50 as a non-covered expense.

争端

Is the 雇主 responsible for payment of charges related to vision care for the 员工’s daughter to the extent those charges exceed the amount allowable under the Plan?

各方立场

员工: The 雇主 should pay for the charges related to the lenses, frames and examination for the 员工’s daughter. The physician has stated that she had outgrown her glasses and required new ones.

雇主: 付款 has been made according to the limits established in The Benefit Plan. The schedule of charges allows $20.00 for an examination, $14.镜框00美元，20美元.00 for single lenses (maximum two) if the beneficiary meets the prescription limitation. These charges were paid to the maximum limit under the Vision Care Program of the 雇主’s Plan.

Applicable Regulations

Article III, Section C of The 雇主’s Plan provides as follows:

(1)

实际的费用
到
好处 最大数量 频率

视力检查 $ 20.00 每24个月一次

Per Lens (maximum = 2) 每24个月一次
O单一视力 10.00
o双焦 30.00
阿三焦点的 20.00
o透镜状 25.00
联系啊 15.00

帧 14.00 每24个月一次

(2) Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lenses must improve visual acuity by at least one line on the standard chart.

(3) 除外责任包括:

(a) Sunglasses (other than Tints No. 1、No . 2);
(b) Extra charges for photosensitive or anti-reflective frames.

讨论

The Plan allows coverage for vision care services on a limited basis. The schedule of charges (Article III, C (1)) defines the maximum amount provided and the 雇主 has made payment accordingly.

的意见

The Trustees are of the opinion that the 雇主 is not responsible for the payment of charges related to vision care for the 员工’s daughter to the extent those charges exceed the maximum amount allowable under the Plan.