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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: 88-132 - 1989年8月22日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 an 员工’s spouse under the terms of the 雇主 Benefit Plan.
背景事实
The Complainant’s spouse’s employer has a group health plan for employees such as the Complainant’s spouse. 1988年11月，她的雇主换了保险公司. The complainants spouse states that she elected not to enroll in the new plan offered by her employer because the new plan did not provide the same level of coverage as the previous plan and because she is covered as a dependent under the health benefits plan established by her husband’s employer, 被申请人. The Complainant has submitted a letter from his spouse’s employer stating that his spouse signed a waiver and does not have health insurance through her employer.
The Respondent has refused to pay the medical expenses incurred by the Complainant’s wife since December 1988. Explanation of Benefits (EOB) forms from 被申请人’s insurance carrier indicate that payment was disallowed pending receipt of other insurance payment information.
争端
Is 被申请人 required to provide full benefits for the covered medical expenses incurred by the Complainants spouse under the terms of the 雇主 Benefit Plan?
双方立场
Position of the 原告: The Complainant’s spouse is not enrolled in the group medical plan offered by her employer; therefore, 被申请人 is responsible for payment of her covered medical expenses.
Position of 被申请人: Because the Complainant’s wife is employed and medical coverage is available as part of her employer’s benefits package, her employer’s plan should be the primary plan for payment of her medical expenses and 被申请人’s plan should be secondary.
相关的规定
Article I (1), (2), (4) and (7) of the 雇主 Benefit Plan provide:
第一条-定义
下列术语具有本协议规定的含义:
(1) “雇主”指(雇主名称).
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1988, 如不时修订及任何后续协议.
(4) “员工” shall mean a person working in a classified job for the 雇主, 有资格获得本协议项下的福利.
(7) “Dependent” shall mean any person described in Section D of Article II hereof.
第二条D. (1)雇主福利计划规定:
第二条-资格
The persons eligible to receive the health benefits pursuant to 第三条 are as follows:
D. 合格的家属
Health benefits under 第三条 shall be provided to the following members of the family of any 员工, 养老金领取者, or disabled 员工 receiving health benefits pursuant to paragraphs A, B, 或本条第2款的规定:
(1) A spouse who is living with or being supported by an eligible 员工 or 养老金领取者;
第三条. A. (10) (f) of the 雇主 Benefit Plan states in pertinent part:
(10) 一般规定
(f) Non-Duplication
The health benefits provided under this Plan are subject to a non-duplication provision as follows:
1. Benefits will be reduced by benefits provided under any other group plan, including a plan of another 雇主 signatory to the Wage Agreement, 如果是其他计划:
(i) does not include a coordination of benefits or non-duplication provision, or
(ii) includes a coordination of benefits or non-duplication provision and is the primary plan as compared to this Plan.
讨论
第二条D. (1) of the 雇主 Benefit Plan states that health benefits coverage under 第三条 shall be provided to an 员工’s spouse who is living with or being supported by an eligible 员工. The Respondent does not dispute that the Complainants spouse is eligible for health benefits coverage. 然而, 被申请人 contends that the group medical plan offered by the Complainant’s spouse’s employer should be her primary insurer and 被申请人’s plan should be secondary.
第三条. A. (10)(f) of the Plan provides for non-duplication of benefits by an 雇主 Benefit Plan and another group plan in situations where a beneficiary is covered by both plans. This non-duplication provision precludes duplicate payments for services and limits payments to the total allowable charges for covered services. 第三条. A. (10) (f) also states the criteria to be applied in determining whether the 雇主 Benefit Plan or another group plan is primary. One of the criteria stipulates that the plan covering the patient other than as a dependent will be the primary plan. The Complainant’s spouse in this instance has waived enrollment in a group medical plan offered by her employer. 因此, she is not covered by any other group plan and the non-duplication of benefits provision does not apply in this situation.
受托人的意见
The Respondent is required to pay the covered medical expenses incurred by the Complainant’s spouse under the terms of the 雇主 Benefit Plan.