______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 1981年10月27日

Board of Trustees: Harrison Combs, Chairman; John J. 奥康奈尔，受托人. 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 health benefits beyond the scheduled continuation of coverage by the 雇主 under the terms of the 雇主’s Benefit Plan and hereby render their opinion on the matter.

背景事实

员工, 谁的出生日期是8月18日, 1951, worked for the 雇主 from 1973 to October 11, 1979, when he became disabled due to a mining injury.

He received Workers’ Compensation Benefits as well as supplemental payments from Sickness and Accident Benefits from February 24, 1980,到2月28日, 1981.

The 雇主 provided the 员工 with health and other non-pension benefits from October 11, 1979,到2月28日, 1981.

The 雇主’s insurance carrier refused to pay health services bills for charges incurred 2月28日以后, 1981. 员工 complained that he was not notified that his benefits had been terminated as of February 28, 1981.

争端

Is the 雇主 responsible for providing benefits beyond the 12-month continuation of coverage period when the 员工 is not notified that his eligibility for benefits has expired?

双方立场

Position of 员工: 员工 feels that 雇主 should pay the health charges incurred 2月28日以后, 1981, because the 员工 was not notified that his eligibility had expired.

Position of 雇主: The 雇主 is only required to provide health benefits coverage for the greater of the period of the 员工’s eligibility for Sickness and Accident benefits or the period set forth in Article III, E (1)(a). There is no contractual requirement that an 雇主 advise disabled employees of the date they cease to be eligible for benefits.
相关的规定

Article III, E (1)(a); (a), (d) of the 雇主’s Benefit Plan which provides:

E. 一般规定

(1) 续保

(a) 裁员

If an 员工 ceases work because of layoff, 健康的延续, 视力保健, life and accidental death and dismemberment insurance coverage is as follows:

工作小时数 保险期限
雇主 in the 24 Calendar Month 继续从
Period Prior to the Date Last Worked the Date Last Worked

- 2000小时或更长时间 月结余
加12个月

- 500或以上但不超过 月结余
2000小时 加6个月

-少于500小时 30天

(b) 残疾

Except as otherwise provided in Article II, C, if an 员工 ceases work because of disability, the 员工 will be eligible to continue health, 视力保健, life and accidental death and dismemberment insurance coverage while disabled for the greater of (i) the period of eligibility for Sickness and Accident benefits, or (ii) the period as set forth in the schedule in (a) above.

(d) Maximum 续保

In no event shall any combination of the provisions (a), (b), or (c) above result in continuation of coverage beyond the balance of the month 加12个月 from the date last worked.

讨论

根据第三条, E (1)(b) of the 雇主’s Plan, 员工s who cease work because of disability are eligible for continuation of coverage for the greater of the period of eligibility for Sickness and Accident benefits or the periods set forth in Article III, E (l)(一). 然而, 根据第三条, E (1)(e), continuation of coverage may not extend beyond the balance of the month 加12个月 from the last date worked.

员工 ceased work because of disability on October 11, 1979, and received Sickness and Accident benefits from February 24, 1980,到2月28日, 1981. The 雇主 provided continued coverage from October 11, 1979,到2月28日, 1981, a period in excess of 16 months. 因此, the 雇主 clearly fulfilled his obligations 根据第三条, 雇主计划的E项.

雇员索赔, 然而, that he was entitled to additional coverage, 2月28日以后, 1981, because the 雇主 did not notify him that his eligibility had expired. The 雇主’s Plan does not require the 雇主 to notify 员工s of the expiration date of their coverage.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for providing benefits for the 员工 beyond the maximum period stipulated in the 雇主’s Benefit Plan.