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受托人的意见
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在再保险

原告: 被解雇的员工
被申请人: 雇主
ROD案例编号: 88-279——1990年7月25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.

根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 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 under the terms 雇主福利计划的成员.

背景事实

投诉人于1981年6月18日开始在被投诉人的机密职位上工作. 1990年2月15日，他被解雇，被告停止经营. 根据皇冠搏彩中心网站组织的记录, 投诉人工作时间超过2小时,在2月15日前的24个月内，为答辩人提供10,000小时的时间, 1990, 他上次约会的对象.

The Complainant claims that the Respondent has failed to maintain the health benefits coverage required by the terms of the National Bituminous Coal Wage Agreement (“Wage Agreement”). Information provided by the Complainant indicates that the Respondent provided coverage through Connecticut General Insurance for some period during 1987. 被告随后从2月1日起通过诺贝尔集团福利提供保险, 1987年至1988年11月8日, 并从11月28日起通过公积金人寿和意外保险公司投保, 1988年至3月31日, 1989. 被告根据旅行者保险公司于6月1日实施的一项计划提供了保险, 1989. The Complainant has submitted a copy of the Summary Plan Description which indicates that benefit payments under that plan are subject to a $300 deductible 每个家庭 and, 之后, 福利最高可达服务成本的80%. The beneficiary is responsible for the remaining 20% of covered expenses until the maximum yearly out-of-pocket amount of $1,每个家庭达到500美元. 除了, the types of benefits provided under that plan are different from those that are required under Article III 雇主福利计划的成员, 而且没有提供视力保健保险. 申诉人指出，他通过旅行者保险公司获得的保险已于4月1日终止, 1990.

申诉人提交了1987年10月至1990年1月期间未付医药费的副本, 还有催收公司的催收通知. 申诉人说，被投诉人同意负责支付未付的医药费, 但没有支付任何款项. The Complainant contends that the Respondent is responsible for payment of the covered medical expenses incurred during his period of employment and for providing continued health benefits coverage for him as a laid-off Employee.

争端

Whether the Respondent is responsible for payment of the Complainants unpaid medical bills and for providing health benefits coverage for the Complainant as an active Employee and as a laid-off Employee at the level prescribed by the 雇主 好处 Plan.

双方立场

Position of the 原告: The Respondent is responsible for payment of the unpaid medical bills incurred by the Complainant and his eligible dependents and for the 健康的延续 benefits coverage for the Complainant as a laid-off Employee at the level prescribed by the 雇主 好处 Plan.

Position of the 被申请人: The Respondent has not replied to repeated correspondence from Funds’ staff requesting its position in this dispute.

相关的规定

1984年和1988年《皇冠搏彩中心网站》第20 (c)(3)(i)条有关部分规定:

(3)(i)各签署雇主应建立并维持员工福利计划，以提供, 通过保险公司实施, 本协议所涵盖的雇员以及领取养老金者的健康和其他非养老金福利, 1974年养恤金计划和信托皇冠搏彩中心网站, 谁的最后一个签署人曾受雇于该雇主. The benefits provided by the 雇主 to its eligible Participants pursuant to such plans shall be guaranteed during the term of this Agreement by that 雇主 at levels set forth in such plans.

雇主福利计划第I(1)、(2)、(4)条规定:

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) “工资协议”系指1984(1988)年全国烟煤工资协议。, 如不时修订及任何后续协议.

(4) “雇员”系指为雇主从事保密工作的人员, 有资格获得本协议项下的福利.

第二条A款. 雇主福利计划第(1)及(4)条规定:

根据第三条有资格领取健康津贴的人员如下:

A. 积极的员工

第III条规定的福利应提供给下列任何员工:

(1) is actively at work* for the 雇主 on the effective date of the Wage Agreement; or

(4) 新雇员从为雇主工作的第一天起就有资格享受健康福利.

第三条A. 雇主福利计划的第(8)和(9)部分规定:

第三条-福利

A. 健康的好处

(8) 自付额

Certain benefits provided in this Plan shall be subject to the co-payments set forth below and such co-payments shall be the responsibility of the Beneficiary. 计划管理人应执行被认为适当的程序，以实现这些共同支付的目的。.

承保健康福利的共同支付额确定如下:

好处 是否值得

(a)作为门诊的医生服务 工作组:7美元.每次访问50元
如A部分所述 每12个月最多150美元
(2)和医生在con- 期间(*)每个家庭.
与利益集的连接 非工作小组-每次访问$5
第四节第(3)段 每12个月不超过100美元
(c)但只适用于事前和事后 期间(*)每个家庭.

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*积极工作的雇员包括在9月30日积极工作的雇主雇员, 1984年1月31日, 1988), 并在工资协议生效之日起两周后返回雇主的工作岗位.
产前检查如果医生
另外收费
除费用外
交付和(g)段
通过(m)， (n)段除外
住院手术，第(o)段
以及第A(7)条第(f)段.

(b) 处方药和胰岛素，每份5美元，或者再加到
如第A(4)条所述及 每12个月最多50元(*)
住院后带回家的药 每个家庭.
中所述的禁闭 注:为了这个共同支付的目的
第A (1) (A)条. 供应、处方或补充
应被视为每30天(或
部分供应.

If an employee is covered under an employee Plan (established pursuant to the NBCWA of 1978) by more than one signatory employer during a 12-month period(*), 员工在此期间支付的共付费用总额将计入12个月(*)的最大值.

(9) 视力保健计划

实际收费至
(一)利益 最大数量 频率的限制

视力检查 $20 每24个月一次
每镜头(最大= 2) 每24个月一次

-单一视力 10
——双焦 15
——三焦点的 20
——透镜状 25
——联系 15

帧 14 每24个月一次

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12个月期间从下列日期开始:3月27日, 1988; March 27, 1989; March 27, 1990; March 27, 1991年和3月27日, 1992.

第三条D. 雇主福利计划第(1)(a)条规定:

D. 一般规定

(1) 续保

(a) 裁员
如果雇员因裁员而停止工作, 健康的延续, 人寿、意外死亡和肢解保险的保险范围如下:

工作时数
24 .雇主
连续日历月
紧接前一时期 保险期限
雇员入职日期 继续
最后的工作 最近工作日期

2000小时以上 月加余额
12个月
500或更多，但少于 月加余额
2000小时 6个月
少于500小时 30天

讨论

Article XX Section (c)(3)(i) of the 1984 and 1988 Wage Agreements requires a signatory 雇主 to establish and maintain an 雇主 好处 Plan to provide health and other non-pension benefits for it Employees. The Wage Agreements stipulate that benefits provided by an 雇主 pursuant to such Plan shall be guaranteed during the term of the Agreement by that 雇主 at levels set forth in such Plan.

第二条A款. 雇主福利计划的成员 provides health benefits coverage for active Employees working in classified jobs for a signatory 雇主. 第三条0. (1) (a) provides continued benefits coverage for laid-off Employees for a defined period based upon the number of hours worked for the 雇主 during the 24-month period immediately prior to the date last worked. Inasmuch as the Complainant was actively employed in a classified position by the Respondent until he was laid off on February 15, 1990, 答辩人负责在其在职期间提供医疗保险. 由于投诉人工作时间超过2小时,在2月15日之前的24个月期间内，为答辩人提供000小时, 1990, the Respondent is responsible for the continuation of the Complainant’s health benefits coverage for the remainder of February 1990 plus twelve months, 符合第三十条的规定. 雇主福利计划的成员.

第三条A. 的“雇主福利计划”列明各项福利, 包括视力保健保险, 哪些是在雇主福利计划下提供的. 第三条A. (8) 雇主福利计划的成员 specifies the co-payments which are the responsibility of the beneficiary for medical services and prescriptions. 提供给员工的福利水平, Pensioners and their dependents and survivors are established through collective bargaining and may not be unilaterally changed by an 雇主. The Respondent’s use of a non-conforming health coverage plan is inconsistent with the provisions of the Wage Agreement and the 雇主 好处 Plan. The Respondent is responsible for providing health benefits coverage for the Complainant and his eligible dependents at the level specified in the 雇主 好处 Plan.

受托人的意见

The Respondent is responsible for payment of the covered medical expenses incurred by the Complainant and his eligible dependents during his eligibility for coverage as an active Employee and as a laid-off Employee under the terms 雇主福利计划的成员. The Respondent is also responsible for the continuation of the Complainant’s health benefits coverage at the level specified in the Wage Agreement and the 雇主 好处 Plan for the period determined pursuant to 第三条0. (1) (a)计划.