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受托人的意见
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 1988年9月26日

董事会:Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, 并根据美国劳工部授予的豁免授权, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for an Employee’s son under the terms of the Employer Benefit Plan.

背景事实

The Complainant has been employed by the Respondent in a classified position since October 31, 1972. 投诉人的儿子, 谁是7月11日出生的, 1966, was covered as a dependent under the Respondent’s Benefit Plan until he attained age 22; his coverage was terminated on August 1, 1988. 提供给皇冠搏彩中心网站的资料显示结肠造口术, 仅次于枪伤, 1988年5月在申诉人的儿子身上做的手术. The Complainant claims that his son is entitled to health benefits coverage beyond age 22 in accordance with Article II. D. (5)雇主福利计划及Q & A H-6(81) (copy enclosed herein) because he became disabled as a result of an injury prior to attaining age 22 and will remain disabled until further surgery is performed. 申诉人说，他的儿子不能工作，完全依靠他养活. 主治医生提交的一份声明表明需要进一步手术, 需要住院大约10天, 需要重新连接投诉人儿子的结肠吗.

The Respondent states that the Complainant’s son is no longer eligible for health benefits coverage under the Employer Benefit Plan because the Complainant’s son has attained age 22 and his current disability is not continuous or permanent. The Respondent further contends that it has fulfilled its obligations under the Plan by informing the Complainant of the conversion privilege under the Plan and his son’s right to continued coverage in accordance with COBRA regulations.

Dispute

Whether the Respondent is responsible for providing health benefits coverage for the Complainant’s son beyond age 22 as a disabled dependent.

双方立场

Position of the Complainant: The Respondent is responsible for providing health benefits coverage for the Complainant’s son as a disabled dependent because his son became disabled prior to attaining age 22 and will remain disabled until further surgery Is performed.

Position of the Respondent: 投诉人的儿子 is no longer eligible for health benefits coverage under the Employer Benefit Plan because the Complainant’s son has attained age 22. 投诉人的儿子 does not qualify for coverage as a disabled dependent because his current disability is not continuous or permanent.

相关的规定

Article II 0. (5)雇主福利计划规定:

第二条-资格

根据第三条有资格领取健康津贴的人员如下:

D. 合格的家属

Health benefits under Article III shall be provided to the following members of the family of any Employee, Pensioner, 或根据A段领取健康福利的残疾雇员, B, 或本条第2款(C)项:

(5) 受抚养儿童(任何年龄), 合资格雇员的, 领取养老金者或配偶, who are mentally retarded or who become disabled prior to attaining age 22 and such disability is continuous and are either living in the same household with such Employee or Pensioner or are confined to an institution for care or treatment. Health benefits for such children will continue as long as a surviving parent is eligible for health benefits.

Article III D. 雇主福利计划第(1)(h)及3(b)条规定:

第三条-福利

D. 一般规定

(1) 续保

(h) COBRA延续保险

尽管有上述规定, this Plan shall comply with the health care continuation coverage provisions of Section 601-608 of ERISA and Section 162 (i) and (k) of the Internal Revenue Code, 于1月31日或之后开始的计划年度的第一天生效, 1988. 计划管理人应使用适当的语言解释员工的, Beneficiaries’ and Pensioners’ rights under COBRA in the next Summary Plan description booklet distributed.

(3) 转换特权

(b) Health Benefits

当医疗保险终止时, 受益人可以, 在应用程序, convert, without medical examination to a policy issued by the insurance carrier provided such application is made to the insurance carrier within 31 days after the date coverage terminates. 保单类型, coverage and premiums therefor are subject to the terms and conditions set forth by the insurance carrier.

Discussion

Article II D. (5) of the Employer Benefit Plan stipulates that health benefits coverage will be provided to dependent children of any age who are mentally retarded or who become disabled prior to attaining age 22, 残疾是持续的. Q & A H-6 (81) provides that “a person is `mentally retarded or disabled’ if the person has any professionally determinable physical, mental, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.”

The Complainant contends that his son is totally dependent upon him at the present time and that the Respondent should provide health benefits coverage to him while he remains dependent. 虽然申诉人的儿子由于结肠造口手术目前可能有一些身体上的限制, a colostomy, 其本身, 是否会妨碍一个人脱离父母独立生活或运作. Furthermore, the information provided to the Funds indicates that both the Complainant and the attending physician expect that the Complainant’s son’s health will be restored when the upcoming surgery to reconnect his colon is completed. Inasmuch as the Complainant’s son does not have a physical impairment which is considered continuous and which precludes his living or functioning independently of his parents, 根据第二条，他没有资格作为残疾受抚养人享受医疗福利. D. (5) of the Plan. Accordingly, the Respondent is not responsible for providing health benefits coverage for the Complainant’s son beyond age 22. The Respondent has fulfilled its obligation under the Plan by informing the Complainant of the conversion privilege and his rights under COBRA, 符合计划的条文.

受托人的意见

The Respondent is not responsible for providing health benefits coverage for the Complainant’s son beyond age 22.