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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-413 – December 2, 1987
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了这一争议的事实和情况，该争议涉及根据雇主福利计划的条款向医生提供门诊就诊和免疫接种的共同支付健康福利.
Background Facts
雇员及其家属因家庭医生在1980年至1986年的六年间提供的服务而产生了未偿余额. 1986年4月，医生起诉雇员，要求收回欠款. 尽管雇员坚持医生的律师告知他的律师雇主同意支付未付的费用, such charges have not been paid.
雇主说，1986年5月，雇员要求对他的医生试图收取的费用不予追究. 雇主通过与其索赔管理人员和雇员医生办公室的联系声明, 它确定已按照雇主福利计划的规定提出并偿还了所有承保服务的索偿要求. 雇主提交的文件表明未付费用为585美元.00 for physician co-payments and $165.00 for non-covered services. 后一项收费代表免疫接种(白喉), tetanus, polio, measles, 腮腺炎及风疹)于1983年提供给雇员14岁的女儿. 雇主指出，没有证明雇员女儿接种疫苗的医疗必要性, and therefore, 雇主福利计划不包括免疫接种. 雇主联系了雇员并解释了这一点, 因为未支付的余额是由于他未能及时支付共同付款和未支付的费用, he could not be held harmless. In addition, 有关的某些服务是在雇主福利计划中没有“保持无害”条款之前提供的.
Dispute
雇主是否有责任支付雇员未付的医疗服务费用?
Positions of the Parties
雇员职位:雇主负责支付未付的医疗服务费用.
雇主的立场:雇主不负责支付代表共同支付的费用，因为这些费用是雇员的责任. 雇主也不负责支付免疫接种费用, 因为他们不在雇主福利计划范围内.
Pertinent Provisions
Article III. A. (3)(o) 2. of the Employer Benefit Plan states:
(o) Primary Medical Care – Miscellaneous
2. 为免疫接种提供福利, allergy desensitization, injections, pap smears, 筛查高血压和糖尿病, and examinations for cancer, blindness, 耳聋及其他医学上必要的筛查和诊断程序.
Article III. A. 雇主福利计划(Employer Benefit Plan)的第(8)部分规定:
(8) Co-Payments
本计划中提供的某些福利应受下述共同支付的约束，此类共同支付应由受益人负责.
For purpose of this paragraph (8), 工作组应被视为第二条A和C第(3)款所述的受益人及其合格的受扶养人. 非工作小组应被视为第二条B中所述的受益人, C(1), C(2)和E及其合资格的家属.
承保健康福利的共同支付额确定如下:
Benefit Co-Payment
(a) Physician services as an out- Working Group– $7.50 per visit
patient as set forth in section up to a maximum of $150 per 12-
A(2) and physician visits in con- month period(*) per family.
nection with the benefits set forth
in section A(3), paragraph (c) but Nonworking Group– $5 per visit
only for pre- and post-natal visits up to a maximum of $100 per 12-
if the physician charges separately month period(*) per family.
for such visits in addition to the
charge for delivery, and paragraphs
(g) through (m), paragraph (n) ex-
cept inpatient surgery, paragraph
(o) and section A(7) paragraph (f).
(b) Prescription drugs and insu- $5 per prescription or refill up
lin, as set forth in section A(4) to $50 maximum per 12-month period
and take-home drugs following a hos- (*) per family. Note: For pur-
pital confinement as set forth in poses of this co-payment provision,
section (A)(1)(a). a prescription or refill shall be
deemed to be each 30 days (or frac-
tion thereof) supply.
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12个月期间从下列日期开始:3月27日, 1984; March 27, 1985; March 27, 1986; and March 27, 1987.
Discussion
Article III. A. 雇主福利计划(Employer Benefit Plan)第(8)条规定，门诊医生服务须支付由雇员负责的共付费用. Therefore, 雇员负责支付未付的费用，这些费用代表共同支付, up to the yearly maximum of $150.00, pursuant to Article III. A. (8) of the Plan.
Article III. A. (3)(o) 2. 《官方网站》规定，在医疗上有必要时提供免疫接种福利. 在进行免疫接种时，病人大约14岁. 在那个年龄，通常不接受儿童免疫接种. 提交的指控没有说明接种疫苗的原因. 因为没有确定雇员的女儿进行免疫接种的医疗必要性, 雇主不负责与免疫接种有关的费用.
Opinion of the Trustees
雇员负责支付根据第三条规定的共同支付费用. A. (8) of the Employer Benefit Plan. 雇主不负责支付雇员女儿的免疫接种费用.