______________________________________________________________________________
受托人的意见
______________________________________________________________________________
在再保险
发牢骚的人 : 养老金领取者
被申请人: 雇主
ROD案例编号:81-260,1983年8月29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 篇文章中,我X of the United Mine Workers of America (“UMWA”) 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 benefit coverage for a pensioner who did not enroll in 医疗保险 B部分, 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
Funds’ records show that the Complainant was born January 1, 1917. His pension from the 1974 Pension Plan was effective February 1, 1981.
The Complainant did not enroll in 医疗保险 B部分 during the enrollment period prior to reaching age 65.
During 1982 the Respondent’s insurance carrier denied payment of health services charges which were incurred by the Complainant because he was not enrolled in 医疗保险 B部分.
In the interim, the Complainant has enrolled in 医疗保险 B部分.
争端
Is the Respondent responsible to provide health benefits coverage for the Complainant during the period that the Complainant failed to enroll in 医疗保险 B部分?
双方立场
Position of Complainant’s Representative: The Respondent is responsible for payment of the health services charges which were incurred by the Complainant during the period he was not enrolled in 医疗保险 B部分 because the Respondent had not advised him of the requirement for enrollment.
Position of the 被申请人: Complainant was orally advised to enroll for 医疗保险. 也, this requirement is contained in the Summary Plan Description booklet of the 雇主’s Benefit Plan.
相关的规定
篇文章中,我. (1), (2), (5) and (6) of the 雇主’s Benefit Plan provides:
第一条-定义
The following terms shall have the meanings herein set forth:
1. “雇主”指(煤炭公司)
2. “Wage Agreement” means the National Bituminous Coal Agreement of 1981, as amended from time to time and any successor agreement.
5. “Pensioner” shall mean any person who is receiving a pension, other than (i) a deferred vested pension based on less than 20 years of credited service, or (ii) a pension based in whole or in part on years of service credited under the terms of 第二条 G of the 1974 Pension Plan, or any corresponding paragraph or any successor thereto, 根据1974年退休金计划(或其任何后续计划), whose last classified signatory employment was with the 雇主, 以计划第二条B款的规定为限.
6. “Beneficiary” shall mean any person who is eligible pursuant to the Plan to receive health benefits as set forth in 第三条 hereof.
第二条. B. 雇主福利计划第(1)(a)及(b)条规定:
第二条-资格
Health benefits and life insurance under 第三条 hereof shall be provided to Pensioners as follows:
(1) Any Pensioner who is not again employed in classified signatory employment subsequent to
(a) such Pensioner’s initial date of retirement under the 1974 Pension Plan, and
(b) 6月7日, 1981, 都有资格作为养老金领取者享受以下的保险, 并受本计划所有其他条款的约束. Notwithstanding (i) and (ii) of the definition of Pensioner in 篇文章中,我 (5) of this Plan, any such Pensioner who was eligible for benefits under the 1974 Benefit Plan as a Pensioner on December 5, 1977, 都有资格享受这些福利, 受本计划所有其他条文规限.
第三条. A. 雇主福利计划第10(d)条规定:
第三条-福利
A. 健康的好处
10. 一般规定
(d) 医疗保险
Benefits provided under the Plan will not be paid to any Beneficiary otherwise eligible if such Beneficiary is eligible for Hospital Insurance coverage (Part A) of 医疗保险 where a premium is not required and/or Medical Insurance coverage (B部分) of 医疗保险 unless such Beneficiary is enrolled for each part of 医疗保险 for which Beneficiary is eligible. Any such Beneficiary who is enrolled in a 医疗保险 program shall receive the benefits provided under the Plan only to the extent such benefits are not provided for under 医疗保险.
讨论
The Complainant’s Representative claims that the Respondent did not advise the Complainant that he was required to enroll in 医疗保险, B部分. 然而, the 雇主’s Benefit Plans of 1978 and 1981 provide that a Beneficiary who is eligible for 医疗保险, A、B部分, must enroll for each part before benefits coverage would be provided under the Plan.
The Respondent claims that Complainant was orally advised to enroll in 医疗保险 by its Division personnel office at the time that he retired. 也, each Employee and Pensioner was issued a Summary Plan booklet of the Benefit Plan.
受托人的意见
The Trustees are of the opinion that Complainant was not entitled to benefits during the period in question because he failed to enroll in 医疗保险, 根据雇主福利计划的要求.
Whether or not Respondent notified Complainant individually of the requirement to enroll is immaterial, as the requirement is included in the Summary Plan Description. 因此, the Respondent is not responsible for the provision of benefits coverage for the Complainant and his dependents during the period he was eligible for, 但没有注册, 医疗保险, B部分.