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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 84-542——1988年3月22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 under the terms 雇主福利计划的成员 for a 养老金领取者 who failed to enroll in 医疗保险B部分.
背景事实
养老金领取者是1974年养老金计划62岁退休养老金的接受者. 5月16日，他年满65岁, 1986, 因此有资格参加医疗保险A部分和B部分, 5月1日生效, 1986. 他参加了医疗保险A部分(医院保险), but refused enrollment in 医疗保险B部分 (supplementary medical insurance) at that time.
从8月17日开始, 1986年至12月24日, 1986, the 养老金领取者 incurred several medical bills for both inpatient and outpatient services. 领取退休金者声称，根据第三条. A. (10)(d)雇主福利计划 his failure to enroll in 医疗保险B部分 should result in his loss of benefits associated with Part B only; the 雇主 should not cease to provide payment of all benefits under the 雇主 Benefit Plan.
The 雇主 states that it provided the 养老金领取者 with a copy 雇主福利计划的成员 which advises a Beneficiary of his obligation to enroll in all parts of 医疗保险 for which he is eligible. The 雇主 claims that benefits provided under the Plan are not payable to a Beneficiary unless he is enrolled for each part of 医疗保险 for which he is eligible, 如第三条所述. A. (10)(d) 1. 雇主福利计划的成员. The 雇主 states that since the 养老金领取者 did not satisfy his obligation to enroll in each part of 医疗保险 for which he was eligible, the 雇主 is not responsible for payment of any of the 养老金领取者’s outstanding medical charges.
争端
Is the 雇主 responsible for providing health benefits under the 雇主 Benefit Plan when the 养老金领取者 failed to enroll in 医疗保险B部分?
双方立场
Position of the 养老金领取者: The 养老金领取者 claims that he failed to enroll in 医疗保险B部分 but that this does not make him ineligible for health benefits provided under the 雇主 Benefit Plan.
Position of the 雇主: The 雇主 maintains that since the 养老金领取者 failed to enroll in 医疗保险B部分, 他没有资格享受雇主福利计划提供的健康福利, 根据第三条. A.(10)(d) 1. 计划的详情.
相关的规定
第三条. A. 《皇冠搏彩中心》(10)(d)的相关部分规定:
(d) 医疗保险
1. 适用于70岁及以上的雇员, 领取养老金者和未亡配偶, the benefits provided under the Plan will not be paid to a 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 (Part B) of 医疗保险 unless such Beneficiary is enrolled for each part of 医疗保险 for which such 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.
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The Plan Administrator shall give written notification of the obligation to enroll with respect to 1. above … Said notice shall explain the limited annual enrollment period and the effect of failing to enroll if retirement should occur prior to the next enrollment period. 未提供此类通知不免除任何注册义务.
讨论
第三条. A. (10)(d\J 雇主福利计划的成员 states that the benefits provided under the Plan will not be provided to a Beneficiary unless such Beneficiary is enrolled in each part of 医疗保险 for which he is eligible. 养老金领取者在1986年5月有资格参加医疗保险A部分和B部分. 当时，领取养老金的人参加了医疗保险A部分，拒绝参加医疗保险B部分.
这位养老金领取者认为，由于他没有参加医疗保险B部分, 他唯一没有资格享受的福利是与医疗保险B部分相关的福利. He claims that the 雇主 is responsible for providing any benefits that would not otherwise be provided under Part B of 医疗保险. 养老金领取者引用争端解决84-271来支持他的立场. 在这种情况下, a Beneficiary had failed to enroll in 医疗保险B部分; however, the 雇主 paid 20% of the charges in question and denied benefits for the 80% that would have been covered under 医疗保险B部分. The opinion of the Trustees was limited to a decision that the 雇主 was not responsible for payment of that portion (80%) of the charges that would have been paid under 医疗保险B部分 if the Beneficiary had been enrolled. Although the 雇主 in that case agreed to provide benefits for the remaining portion (20%) of the charges in dispute, 根据第三条的规定，它显然没有义务这样做. A. (10)(d)雇主福利计划. 因此, the decision in ROD 84-271 does not support the 养老金领取者’s claim here that the 雇主 must pay that portion of charges not otherwise covered by 医疗保险B部分.
The issue of an 雇主’s responsibility to provide benefits for a Beneficiary who is not enrolled in each part of 医疗保险 for which he is eligible has been previously addressed in Resolutions of 争端 84-103, 84-491, 84-497及84-516(随函附上副本). The Trustees concluded in those respective opinions that an 雇主 is not responsible for providing health benefits for a Beneficiary during any period that such Beneficiary was not enrolled in each part of 医疗保险 for which he was eligible. 因为养老金领取者在1986年5月有资格获得医疗保险B部分, 但还没有注册, the 雇主 is not responsible for providing health benefits for the 养老金领取者 until such time as the 养老金领取者 is enrolled in each part of 医疗保险 for which he is eligible.
受托人的意见
The 雇主 is not responsible for providing health benefits coverage for the 养老金领取者 during the period the 养老金领取者 was eligible for, 但没有报名参加, 医疗保险B部分.