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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: 88-544 - 1992年5月7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; Elliot A. 西格尔,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 benefits for vision examinations under the terms of the 雇主 Benefit Plan.

背景事实

The 员工 is an active mine worker eligible for benefits under the 雇主’s health benefit plan. 11月22日, 1989, the 员工’s daughter underwent a routine eye examination with a new lens prescription, for which benefits were provided under 第三条, A of the 雇主’s Benefit Plan. 11月16日, 1991, the 员工’s daughter underwent a routine eye examination and purchased new eyeglass lenses and frames. The 雇主 denied these charges, stating that the 员工’s daughter was not eligible for vision care benefits until November 22, 1991年或以后, in accordance with 第三条. A. (9)雇主的计划.

争端

Is the 雇主 responsible for the payment of the vision expenses incurred by the 员工’s daughter on November 16, 1991?

双方立场

Position of the Claimant: The 雇主 is required to provide vision benefits for the services incurred by the 员工’s daughter on November 16, 1991, as the previous examination was performed in November of 1989, and hence the two examinations were 24 months apart as stipulated in the 雇主’s Benefit Plan.

Position of the 雇主: 第三条, Section A (9) of the 雇主’s Benefit Plan clearly states that vision care benefits are limited to one examination every 24 months. In accordance with this limitation, the 员工’s daughter was not eligible for vision benefits prior to November 22, 1991. Consequently, charges for services on November 16, 1991 were denied.

相关的规定

第三条. A. (9) of the 雇主’s Benefit Plan states in pertinent part:

(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
– 单视觉 10
– 双光眼镜 15
– 三焦点的 20
– 透镜状 25
– 联系 15

帧 14 每24个月一次

Note: The 24-month period shall be measured from the date the examination is performed or from the date the lenses or frames are ordered, 分别, even if the last examination occurred during a prior Wage Agreement.

讨论

第三条. A. (9) of the Benefit Plan provides coverage for a vision examination and/or new lenses and frames once every 24 months. The Plan states that the 24 month period is to be measured from the date of the last examinations, or the date the last lenses or frames were ordered.

The 员工 cites ROD #182 as a precedent in this case. In this ROD the Trustees concluded that, in lieu of any precise definition in the Plan document pertaining to how the 24 months would be measured, that charges incurred on October 6th, 1980 were payable even though the last examination was October 9, 1978, and consequently the two examinations were not precisely 24 months apart. Since both examinations were in the same month, and the two months were 24 months apart, the charges would be eligible. 这一裁决, 然而, was based on a version of the Health Benefit Plan that was in effect from October 1, 1978年至6月7日, 1981. The 1981 version of the Wage Agreement amended the wording of the Plan to include the current definition of 24 months (i.e. 日期到日期). Since the charges in this case were incurred in 1989 and 1991, coverage is determined by the language contained in the 1988 Wage Agreement. 因此, the Trustees conclude that the 雇主 is not required to pay for vision care expenses incurred by the 员工’s daughter on November 16, 1991.

受托人的意见

The 雇主 is not required to provide benefits for the 员工’s daughter’s vision examination and purchase of new lenses and frames on November 16, 1991.