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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: 88-369 - 1991年8月27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 和 circumstances of this dispute concerning reimbursement for health insurance premiums paid by a beneficiary under the terms of the 雇主 Benefit Plan.

背景事实

9月17日, 1987, 在一个机密职位上工作时,被申请人, 申诉人遭受了工伤，因此获得了工人赔偿. The Complainant was unable to return to work 和 he applied for Social Security Disability Insurance (SSDI) benefits on January 25, 1988. 被投诉人作为残疾雇员为投诉人提供持续的健康福利，直至9月30日, 1988. The Complainant then elected to convert to an individual insurance policy 和 he paid premiums to maintain coverage from October 1, 直到他获得SSDI福利.

2月16日, 1990, an Administrative Law Judge determined that the Complainant was eligible for SSDI benefits with a disability onset date of September 17, 1987. 1990年2月21日，申诉人申请了1974年妇女事务部养恤金计划的残疾养恤金. 他的申请获得批准，他选择1988年8月1日为退休金的生效日期. 当被投诉人得知投诉人的伤残抚恤金时, 它恢复了申诉人自养恤金生效之日起的健康福利.

The Complainant claims that 被申请人 should now either reimburse him for the premiums he paid to maintain coverage beyond September 1988 or pay him an amount equal to the Complainant’s medical expenses which would have been 被申请人’s responsibility to pay except for the fact that the Complainant had purchased private insurance.

争端

Whether 被申请人 is required to either provide reimbursement for insurance premiums paid by the Complainant or pay the Complainant an amount equal to the total Plan-covered medical expenses incurred during the period the Complainant paid his own insurance premiums.

双方立场

Position of the 原告: The Respondent is required to reimburse the Complainant for premiums paid to maintain coverage beyond September 30, 1988年,因为, 当时保险费已经支付了, the Complainant did not know that he would eventually be entitled to health benefits coverage as a 养老金领取者 和 he needed insurance coverage in order to obtain ongoing medical treatment of an injury. 另外, 被申请人 should pay the Complainant an amount equal to his total medical expenses which would have been 被申请人’s responsibility to pay if the Complainant had not purchased private insurance.

答辩人的立场:正如受托人在第81-17条中先前的决定所指出的那样, 81-640和84-437, 计划中没有关于偿还受益人支付的健康保险费的规定, 因此, 被申请人 is not required to reimburse the Complainant for premiums he paid to maintain coverage for a period during which he was later determined eligible for coverage as a 养老金领取者. The Respondent is not required to provide payment for the Complainant’s medical expenses which were covered under his individual insurance policy or by other parties because there Is no actual dispute with respect to those expenses.

相关的规定

雇主福利计划第I(1)、(2)和(5)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”指1988年《皇冠搏彩中心》, 如不时修订及任何后续协议.

(5) “养老金领取者”系指领取养老金的任何人, (I)以少于20年的累计服务为基础的递延既得退休金除外, 或(ii)全部或部分根据1974年养恤金计划第ii G条的规定记入的服务年数的养恤金, 或其任何继承者的任何相应段落, 根据1974年退休金计划(或其任何后续计划), 谁的最后一次机密签署工作是在雇主处, 但须符合本计划第II条第8款的规定.

第八条. (1)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:

B. 养老金领取者

根据本办法第三条向养恤金领取人提供的健康津贴和人寿保险如下:

(1) 任何退休金领取者，在

(a) 根据1974年养恤金计划领取养恤金者的最初退休日期;及

(b) 2月1日, 1988, 都有资格作为养老金领取者享受以下的保险, 并受本计划所有其他条款的约束. 尽管本计划第i (S)条对退休金领取人的定义有(i)及(ii)项规定, 在12月5日符合1974年福利计划下领取养老金资格的任何此类养老金领取者.在遵守本计划所有其他规定的前提下，于1977年出生的美国公民均有资格享受此种福利.

第三条. A. 雇主福利计划的第(10)(e)和(f)部分规定:

(10) 一般规定

(e) 代位权

The Plan does not assume primary responsibility for covered medical expenses which another party is obligated to pay or which another insurance policy or other medical plan covers. 承运人之间有什么争议, 计划须, 以下文第1和第2条为准, pay for such covered expenses but only as a convenience to the Beneficiary eligible for benefits under the Plan 和 only upon receipt of an appropriate indemnification or subrogation agreement; but the primary 和 ultimate responsibility for payment shall remain with the other party or carrier.

代表任何受益人支付利益的义务应满足以下条件:

1. upon such Beneficiary taking all steps necessary or desirable to recover the costs thereof from any third party who may be obligated 因此, 和

2. 受益人执行计划管理人合理要求的文件, 包括, 但不限于, 转让:接受第三方付款的权利转让, 以保护和完善本计划从任何该等第三方获得报销的权利.

(f) Non-Duplication

本计划提供的健康福利受以下不重复条款的约束:

1. 根据任何其他团体计划提供的福利，福利会减少, 包括另一签署工资协议的雇主的计划, 如果是其他计划:

(i) 不包括福利协调或不重复条款，或

(ii) 包括福利协调或不重复规定，是与本计划相比的主要计划.

讨论

The issue of whether an 雇主 is obligated to reimburse a participant for premiums paid to purchase private health coverage for a period during which the participant is later determined eligible for coverage from that 雇主 has previously been addressed by the Trustees in RODs 81-17, 81-640, 81-660, 84-437及88-161(随函附上副本). 在这些决定中, the Trustees concluded that the 雇主’s obligation in such situations is limited to reimbursing a beneficiary for Plan-covered medical expenses that are incurred during the beneficiary’s period of eligibility; the 雇主 is not required to reimburse the beneficiary for premiums paid to purchase private health insurance coverage. The National Bituminous Coal Wage Agreement of 1988 和 the 雇主 Benefit Plan established pursuant thereto contain no specific provisions requiring an 雇主 to reimburse beneficiaries for private health insurance premiums paid during a period for which the 雇主 is required to provide coverage pursuant to the Plan. 相应的, 被投诉人不需要偿还投诉人为私人健康保险支付的保费.

第三条. A. 雇主福利计划第(10)(f)条涉及福利“不重复”的问题. 它规定，雇主计划下的福利将被“任何其他团体计划”下的福利所削减.“因为投诉人购买的是个人保险而不是团体保险, 雇主计划下的福利不得因该个人保单所涵盖的福利金额而减少.

The Respondent contends that the Complainant was also involved in an accident during the relevant period 和 that as the result of the accident, 投诉人的某些医疗费用可能由第三方负责. 雇主计划对这些费用的承保由第3条规定. A. (10)(e)标题为“代位求偿权”.“在潜在的第三方责任情况下, the plan “does not assume primary responsibility for covered medical expenses which another party is obligated to pay or which another Insurance policy or medical plan covers."如果被告认为某些费用是第三方的责任, 它可遵循第(e)条所述的程序, 包括要求投诉人在付款前签署赔偿协议.

受托人的意见

被投诉人必须为投诉人作为养恤金领取者提供医疗保险, 8月1日生效, 1988. The Respondent is not required to provide reimbursement for premiums paid by the Complainant for private health insurance coverage between October 1988 和 2月1日990. The Respondent is required to provide benefits for Plan-covered medical expenses that were covered under the individual insurance policy purchased by the Complainant, 但可按照第三条规定的程序进行. A. (10) (e)由于投诉人的事故而可能由第三方负责的费用.