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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案例编号: 81-362——1984年1月30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 conversion of benefits coverage for a laid-off 员工 under the terms of the 雇主’s Benefit Plan hereby render their opinion on the matter.

背景事实

The Complainant was employed by the Respondent for a thirteen month period, 在8月20日被解雇之前, 1982. 在他工作期间, the Complainant worked in excess of 2,被投诉人有000小时的时间, qualifying him for continued health benefit coverage through August 31, 1983, 他收到了.

At the expiration of his period of eligibility, the Complainant exercised his option to 转换 his insurance coverage and mailed a check in the requested amount of $268.19 to the insurance carrier at the designated address in August 1983.

Shortly thereafter, the Complainant’s wife incurred bills for services related to pregnancy. She was advised by the insurance carrier that their 转换ed policy did not provide the same level of coverage as previously provided under the 雇主’s Benefit Plan and, 具体地说, that services related to pregnancy were not covered.

争端

Is the coverage provided under the individual conversion privilege required to be similar to that under the 雇主’s Benefit Plan? Does the Pregnancy Discrimination Act of 1979 require the company to cover these medical bills?

双方立场

Position of the 原告: Coverage provided under the conversion privilege should be similar to that provided under the 雇主’s Benefit Plan. Statutory requirements under the Pregnancy Discrimination Act of 1979 should require coverage of these incurred expenses.

Position of the 被申请人: The 转换ed health insurance coverage does not include pregnancy benefits and is consistent with standard conversion policy coverage available to residents of the state of Virginia where continuation of pregnancy benefits are not required.

有关计划条文

雇主福利计划提供:

第三条D.(3)(b)When health benefits coverage terminates, 受益人可以, 在应用程序, 转换, 未经体检, to a policy issued by the insurance carrier within 31 days after the date-coverage terminates. 保单类型, coverage and premiums therefore are subject to the terms and conditions set forth by the insurance carrier.

讨论

第三条D. (3)(b) of the 雇主’s Benefit Plan provides that a Beneficiary y 转换 to a policy issued by the insurance company if application is made thin the specified time limits. The Complainant was provided with and exercised his conversion option within that time period.

投诉人声称, 然而, that the policy issued by the insurance carrier was inconsistent with that provided under the 雇主’s Benefit Plan. While this was in fact the case, 第三条D. (3)(b) of the 雇主’s Benefit Plan clearly specifies that the type of policy, coverage and premiums offered by the insurance carrier at the time of conversion are subject to the terms and conditions set forth by the insurance carrier. There is no requirement that coverage be the same as that provided under the 雇主’s Benefit Plan. Therefore the obligations of the Respondent, 作为前雇主, were met by virtue of its making available a plan for conversion.

As to the question raised by the Complainant concerning the applicability of the Pregnancy Discrimination Act of 1979, the Trustees regret that they may not comment on whether the insurance carrier’s policy is in violation of the Pregnancy Discrimination Act. The authority granted to them by the Department of Labor to resolve disputes extends only to the resolution of disputes arising of the administration of 雇主 Benefit Plans. The Respondent in the case has fully complied with its obligations under the 雇主’s Benefit Plan.

The remaining dispute concerns a statutory question between an insurance carrier and its policyholder which the Trustees may not address.

受托人的意见

Respondent has complied with its contractual obligations and is not responsible for the payment of charges incurred after the expiration of the Complainant’s eligibility under the 雇主’s Benefit Plan.