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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: 84-484——1988年6月10日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
威廉·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 level of health benefits provided for medical services under the terms of the 雇主 Benefit Plan.
背景事实
The 员工 was treated by a physician who sought payment from his patients directly, 而不是向第三方付款人付款. The 员工 paid the physician’s charges in full at the time the services were rendered and submitted a claim to the 雇主’s insurance carrier for reimbursement. The 雇主’s insurance carrier reduced the payment to the usual and customary amount for the services rendered. The 员工 contends that the insurance carrier should recover from the physician, 代表雇员, 他支付的超出通常和惯例费用的金额.
The 雇主 states that it has communicated in writing to its 员工s that paying the bill when charges are incurred waives their right to protection under the hold harmless provisions of the 雇主 Benefit Plan. It submitted a copy of a company newspaper article dated May 1985 as proof of the written communication. 该公司发言人表示, the newspaper is circulated to all hourly employees at their work site and is used regularly to update them on matters of importance.
争端
雇主是否负责从供应商处进行恢复, 代表雇员, 雇员支付的超额费用?
双方立场
Position of the 员工: The 雇主 is responsible for recovering from the provider, 代表雇员, 雇员在提供服务时支付的超额费用.
Position of the 雇主: The 雇主 is not responsible for recovering from the provider, 代表雇员, 雇员在提供服务时支付的超额费用 because in making such payments, 雇员放弃了保护其免受过高收费的权利.
相关的规定
第三条. A. (10)(g) 2. 的“雇主福利计划”规定:
The 雇主 and the UMWA agree that excessive charges and escalating health costs are a joint problem requiring a mutual effort for solution. In any case in which a provider attempts to collect excessive charges or charges for services not medically necessary, 如计划所界定, 来自受益人, 计划管理人或其代理人应, 经受益人书面同意, 试着解决这个问题, either by negotiating a resolution or defending any legal action commenced by the provider. Whether the Plan Administrator or his agent negotiates a resolution of a matter or defends a legal action on a Beneficiary’s behalf, 受益人不承担任何法律费用, 定居点, 与案件有关的判决或者其他费用, but may be liable for any services of the provider which are not provided under the Plan. The Plan Administrator or his agent shall have sole control over the conduct of the defense, including the determination of whether the claim should be settled or an adverse determination should be appealed.
第三条. A. 《皇冠搏彩中心》(11)(a)部分规定:
除本计划中另有规定的特定除外事项外, 以下情况也不提供福利:
12. 过多的费用.
第三条. A. 《皇冠搏彩中心》第(10)(b)部分规定:
The Plan Administrator is authorized to promulgate rules and regulations to implement and administer the Plan, and such rules and regulations shall be binding upon all persons dealing with the Beneficiaries claiming benefits under this Plan.
讨论
第三条. A. (10)(g) of the 雇主 Benefit Plan provides that the Plan Administrator shall attempt to negotiate with or defend the 员工 against providers who seek to collect excessive fees for their services. 雇主是否协商解决方案或为法律诉讼辩护, the 员工 is not responsible for any expenses in connection with the excessive fee claim. 这被称为该计划的“保持无害”条款.
根据第三条. A. (10)(b), an 雇主 is authorized to promulgate rules and regulations necessary to the administration of the Plan. 如果合理且有效地与员工沟通, 雇主的规则, 包括所有必要的保持无害程序, 对雇员有约束力吗.
在这种情况下, the 雇主 established and communicated to its 员工s a rule that if a physician requires payment in full at the time of service and they comply, they will have no recourse in collecting amounts denied by the 雇主 as excessive charges. 这种规则的目的是防止成本的转移(在这种情况下), 过度收费), by allowing the 雇主 to (1) identify any disagreement between the 雇主 and the health care provider over payment amounts, (2) to intervene with the provider 代表雇员 when a provider’s charges are identified as excessive and (3) to hold the 员工 harmless from a provider’s attempts to collect such charges. While the purpose of the rule is not in question, its reasonableness must be considered. It is a common practice among health care providers to require payment at the time of service. A beneficiary is in no position to refuse payment when he needs medical service from a particular provider. In some rural communities there is not a wide choice of providers of speciality care, thus a rule prohibiting hold harmless protection for all up-front payments is not reasonable. The first time a beneficiary encounters a request for up-front payments from a provider, 他支付账单并要求全额报销是合理的. 之后, it would not be unreasonable to establish procedures which encourage an 员工 to seek care from providers who accept the 员工’s health card.
受托人的意见
The 雇主 is responsible for reimbursing the 员工 for his full expenses. The 雇主 may make an appropriate adjustment with the provider to ensure that no excessive fees have been paid.