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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: 88-205——1990年2月15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 under the terms of the 雇主 Benefit Plan for a 养老金领取者 who failed to enroll in 医疗保险第8部分.

背景事实

The 养老金领取者 is receiving a normal retirement pension under the 1974年退休金计划, 3月1日生效, 1988. He attained age 65 on November 29, 1988. He was enrolled in 医疗保险 Part A, 11月1日生效, 1988, but he did not enroll in 医疗保险第8部分. The 养老金领取者 indicates that the 雇主 has refused to provide health benefits for services rendered during the period in which he was eligible for, 但没有注册, 医疗保险B部分. The 养老金领取者 asks that the 雇主 pay only that portion of his medical expenses for which it would have been responsible as secondary payer had he enrolled in 医疗保险B部分.

争端

Is the 雇主 responsible for providing health benefits coverage for the 养老金领取者 during the period that the 养老金领取者 was eligible for, 但没有注册, 医疗保险第8部分?

双方立场

Position of the 养老金领取者: The 养老金领取者 admits that he forgot to enroll in 医疗保险B部分; he asks that the 雇主 pay only that portion of his medical expenses for which it would have been responsible as secondary payer had he enrolled in 医疗保险B部分.

Position of the 雇主: The 雇主 is not required to provide health benefits for any portion of the 养老金领取者’s medical expenses incurred during the period he was eligible for, 但没有注册, 医疗保险B部分. The 养老金领取者 received adequate notification of his obligation to enroll when he received the Summary Plan Description (SPD), which contained provisions concerning a beneficiary’s responsibility to enroll in each part of 医疗保险 for which he is eligible.
相关的规定

第三条. A. (10) (d) of the 雇主 Benefit Plan provides in pertinent part:

(d) 医疗保险

1. 针对养老金, 以及幸存的配偶, 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 8) 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.

The Plan Administrator shall give written notification of the obligation to enroll with respect to 1. 以上 and of the options to enroll with respect to 2. 以上. 在职员工, such notice shall be given prior to their 65th birthdays, but subsequent to their 64th birthdays. 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. Failure to provide such notification shall not remove any obligation to enroll.

讨论

第三条. A. (10) (d) of the 雇主 Benefit Plan stipulates that the benefits provided under the Plan will not be paid to a Beneficiary unless such Beneficiary is enrolled in each part of 医疗保险 for which he is eligible.

The 养老金领取者 was eligible for 医疗保险第8部分 on November 1, 1988, but failed to enroll. Therefore, under the clear and unequivocal language of 第三条. A. (10) (d), the 雇主 is not required to provide health benefits for the 养老金领取者 from November 1, 1988 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 required to provide health benefits 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, 医疗保险第8部分, consistent with the terms of the 雇主 Benefit Plan.