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受托人的意见
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在再保险

原告:退休老人
被申请人:雇主
ROD Case No: 88-659 – 1993年12月10日

董事会:Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for a Pensioner who failed to maintain enrollment in 医疗保险 Part B.

背景事实

原告, 残疾领取养老金者 under the 1974 Pension Plan, obtained eligibility for 医疗保险 Part A (hospital coverage) and Part B (medical coverage) as a result of his disability. The Pensioner dropped his 医疗保险 Part B coverage in 1989 after inquiries to both the Employer’s claims administrator and 医疗保险 resulted in letters dated March 17, 1988年和3月15日, 1989年分别, stating that until the Pensioner reached 65 the Employer Benefit Plan would provide primary coverage, 其次是医疗保险. The Pensioner contends that he was advised that there was no need to continue his 医疗保险 Part B coverage, 因此, dropped his Part B coverage sometime in 1989.

The Employer sent letters on December 9, 1992 to all disabled Pensioners acknowledging that it had misinterpreted the 医疗保险 secondary payer provisions for the disabled. 另外, the letter stated that any Pensioners who may have cancelled Part B coverage, 或者可能从来没有注册过, needed to (re-)enroll as soon as possible.

The Pensioner says he was informed by 医疗保险 that there will be a penalty assessed when re-enrolling in Part B, making his new premium approximately $60 to $65. The Pensioner contends that he should not be penalized for the errors of others and asks that the Employer provide primary benefits until he is 65.

争端

Is the Employer required to provide health benefits under the Employer Benefit Plan for the disabled Pensioner until he reaches age 65.

双方立场

Position of the Pensioner: The Employer is required to provide primary health benefits for the Pensioner until he is 65 years of age without requiring him to enroll in 医疗保险 Part B, since both the 医疗保险 carrier and the

Employer’s claims administrator concurred that the Employer Benefit Plan is the primary carrier until age 65. Both the Employer’s claims administrator and 医疗保险 advised the Pensioner that he could drop his Part B coverage; therefore, the Pensioner should not be penalized for the errors of others by paying a higher premium.

Position of the Employer: The Employer is not required to provide primary insurance coverage for the Pensioner because 第三条.A. (10)(d) of the Employer Benefit Plan clearly provides that all Pensioners must enroll in, 保持覆盖范围, both Parts A and B of 医疗保险 in order to be eligible for benefits under the Plan.

相关的规定

第三条. A. (10)(d) of the Employer Benefit Plan provides:

(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 B) 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.

2. For Employees age 65 or older the benefits provided under the Plan will be paid to a Beneficiary unless the company is furnished written notice of electing coverage under 医疗保险 rather than coverage under the Plan. Alternatively, the participant may elect to enroll for 医疗保险 as secondary payer.

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. For active Employees 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.

第三条. A. (11) (a) 3. of the Employer Benefit Plan states:

(11) 一般的除外

(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

3. Services furnished by any governmental agency, including benefits provided under Medicaid, Federal 医疗保险 and Federal and State Black Lung Legislation for which a Beneficiary is eligible or upon proper application would be eligible.

讨论

第三条. A. (11) (a) 3. of the Employer Benefit Plan excludes from coverage benefits provided under Federal 医疗保险 for which a Beneficiary is eligible or upon proper application would be eligible.

第三条. A. (10)(d)(1) of the Employer Benefit Plan states 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. 因此, whether the Employer Benefit Plan was primary or not, coverage in 医疗保险 must be maintained in accordance with the Plan. 原告, 残疾领取养老金者, had been enrolled in 医疗保险 Parts A and B, but dropped his Part B coverage in 1989 based on his interpretation of letters from 医疗保险 and the Employer’s claims administrator that stated the Employer Benefit Plan would provide primary coverage. The Employer later advised all its disability pensioners by letter that it had misinterpreted the 医疗保险 secondary payor provision. The letter told them to obtain coverage in Part B as soon as possible, 如果他们还没有这样做的话. The Employer advised Funds’ staff in a telephone conversation on June 2, 1993 that due to its misinterpretation of the 医疗保险 Secondary Payor provision, it will continue to provide primary coverage for all Pensioners who may have inadvertently cancelled their Part B coverage until such time as the Pensioners re-enroll in 医疗保险 Part B, 但不得迟于6月30日, 1993.

The Pensioner states that the penalty assessed on his monthly Part B premium was caused by the incorrect advice of others and that he should not be held responsible for the actions of others. The Pensioner stated that 医疗保险 had advised him that his new premium would be $60 or $65. This does not appear to be correct. 巴尔的摩, Maryland Social Security office has advised Funds’ staff that the 医疗保险 re-enrollment penalty is 10% of the normal monthly premium for each whole year in which the Part B coverage was not in effect. 在退休老人的案例中，他

terminated his Part B coverage sometime in 1989 and re-enrolled in 1993, so he would be penalized for the complete years of 1990, 1991年和1992年. His total penalty would be 30%, or $10.(正常每月保险费= $36).60 X 30% = $10.98) making his total monthly premium $47.58.

第三条. A. (10)(d) of the Plan further provides that the Plan Administrator shall give written notification of a Beneficiary’s obligation to enroll in each part of 医疗保险 for which he is eligible. 在这种情况下, the Pensioner was properly enrolled in Part A and Part B but cancelled his Part B coverage based on his interpretation of information contained in the two letters. The Trustees noted in prior RODs that while the Plan contains a requirement that the Employer notify in writing a 医疗保险-eligible Beneficiary of the obligation to enroll, and by extension to maintain coverage, the Plan clearly states that failure to provide such notification does not remove the Beneficiary’s obligation to enroll or to maintain coverage.

The Trustees have addressed the issue of primary vs. secondary coverage in ROD 88-467 (copy enclosed herein). 在这种情况下, the Pensioner allowed his Part B enrollment to lapse, and there was also a conflict over who was responsible for providing primary coverage. The Trustees concluded in that case that their opinion was concerned solely with the Pensioner’s obligation to maintain 医疗保险 Part B coverage, and could not evaluate or resolve any other dispute or conflict of opinion concerning interpretation of 医疗保险 regulations by other parties. Consistent with the Trustees ruling in ROD 88-467, the Pensioner is required to enroll in, 和维护, his entitlement to Part B in accordance with the Plan, regardless of whether 医疗保险 is a primary or secondary payor.

The Trustees note that while the Plan provisions on 医疗保险 are clear, the Employer has continued coverage through June 30, 1993 to allow adequate time to (re-)enroll in 医疗保险 Part B. The Trustees conclude that the Employer is not obligated by the Plan to provide primary coverage until the Pensioner reaches 65, in lieu of the Pensioner’s enrolling in Part B.

受托人的意见

The Employer is not required to provide benefits for the Pensioner under the Employer Benefit Plan during the period when the Complainant fails to maintain his coverage under 医疗保险 Part B, 6月30日以后, 1993.