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OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
84-457——1988年1月5日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

Pursuant to Article IX 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 benefits coverage for inpatient confinement for mental illness under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse has had multiple hospital admissions for treatments of her mental condition (multiple personality and atypical depression). The 雇主 paid benefits for 90 days during a two year period and denied benefits for confinement after the 90 days. The 员工 states that he did not know about the 90-day limitation.因为他从来没有得到过计划手册.

争端

Is the 雇主 responsible for payment of health benefits for the 员工’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years?

双方立场

Position of the Complainant: The 雇主 is responsible for payment of health benefits for the 员工’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years because the 雇主 did not give the 员工 a copy of the 雇主 Benefit Plan; therefore, the 员工 did not know of the limitation on coverage.

Position of the Respondent: The 雇主 is not responsible for payment of hearth benefits for the 员工’s spouse’s confinement to a hospital for mental illness for more than 90 days within two years. The Company’s 1984 Plan Booklet was provided to every active 员工 at the mine site. The 员工’s spouse’s illness is a long-term mental problem for which inpatient hospital benefits are not provided under the Plan.

受托人解决争议意见. 84-457页

第三条有关规定. A. 雇主福利计划第(I) (e)条规定:

(e)精神病

Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. 当医疗需要时, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, 每一次急性疾病. (More than 90 days of confinement for mental illness over a two-year period, (从住院第一天算起, even if the first day of confinement occurred during a prior Wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Plan will not provide inpatient hospital benefits).

讨论

根据第三条. A. (1) (e)雇主福利计划, benefits are not provided for inpatient hospital confinements for chronic mental illness. An individual is deemed to have a chronic mental problem if he/she is confined for more than 90 days over a two-year period, 从住院第一天开始. The 雇主 has denied benefits for the 员工’s spouse’s inpatient hospital confinements which exceed the 90-day limitation set forth in Article III. A. (1) (e).

The 员工 states that he did not receive a Plan booklet and was unaware of the limitation on coverage for long-term in-patient hospitalization. He contends that no one notified him of the limitation in time to prevent bills for services beyond that period being incurred. He stated to a Funds’ staff member that he worked by himself at the water treatment part of the mine and was perhaps unaware when Plan booklets were passed out. He is not sure exactly how other 员工s received theirs and was unaware that he needed one.

The 雇主 states that every 员工 was provided a 1984 Plan booklet. Two classified workers employed at the time of the 1984 Plan distribution have described to Funds’ staff the procedure followed by the 雇主. They stated that three different booklets were distributed, stapled to their pay checks. They said if an 员工 had to go to the benefits office to get his check, they felt certain the booklets would still have been stapled to the check since the assemblage of the checks with the booklets was handled at that office. 进一步, they stated that all 员工s are usually aware of something special being distributed and would normally ask for their copies of whatever the other men are receiving. Given the miners’ description of the 雇主’s distribution of the 雇主 Benefit Plan, we conclude that the 员工 was furnished with a 1984 Plan booklet which details the 90-day limitation over a two-year period on benefits for hospitalization for mental illness.

受托人解决争议意见. 84-457页

受托人的意见

The 雇主 has fulfilled its responsibility to provide coverage for inpatient confinement for mental illness.