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受托人的意见
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在再保险

原告: 残疾员工
被申请人: 雇主
ROD案例编号: 93-104 - 2004年7月21日

受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D. 哈德逊,
艾略特一. 西格尔.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms 雇主福利计划的成员.

背景事实

投诉人未满55岁, has over 20 years of signatory service and was awarded SSDI benefits effective May 23, 1997. The Respondent is providing health benefits coverage to the Complainant as a disabled Employee under 第二条丙. 雇主福利计划的成员. On
7月5日, 1997, the Complainant was injured by a vehicle driven by an intruder–a neighbor’s son–onto the Complainant’s property. The neighbor’s son was not insured and did not have permission to drive the vehicle. As a result of the accident, the Complainant incurred medical claims totaling approximately $70,000. Under the section titled “Medical 付款s” of the Complainant’s auto insurance policy, 汽车保险公司支付了50美元的最高赔款,000 for “reasonable medical expenses for bodily injury caused by an accident” to the Complainant’s medical providers. 付款后, the Complainant had a balance of approximately $20,000美元的未偿医疗索赔. 申诉人还收到50美元,000 under his uninsured motor vehicle coverage for “damages for bodily injury an insured is legally entitled to collect from the owner or driver of an uninsured motor vehicle.”

The Complainant states that since he has exhausted his medical payments coverage under his auto insurance policy, the Respondent is required to provide coverage for his outstanding medical claims. 然而, the Respondent states that the Complainant’s $50,000 from his uninsured motor vehicle coverage should be used to cover the outstanding medical claims.

争端

Is the Respondent required to provide coverage for the Complainant’s outstanding medical claims incurred on 7月5日, 1997?

双方立场

Position of the 原告: The Respondent is required to provide coverage for the outstanding medical bills which exceed the medical payment coverage provided by his auto insurance policy.

Position of the 被申请人: The Respondent is not required to provide coverage for the outstanding medical claims because the Complainant has not exhausted his coverage under his auto insurance policy.

相关的规定

Article I (1), (2) and (4) 雇主福利计划的成员 provides:

第一条定义

The following terms shall have the meanings herein set forth:

(1) “雇主”指(填上雇主名称).

(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1993, as amended from time to time and any successor 协议.

(4) “Employee” shall mean a person working in a classified job for the 雇主, eligible to receive benefits hereunder.

第二条丙. (1)雇主福利计划规定:

第2条资格

C. 残疾员工

In addition to disabled Pensioners who are receiving pension benefits and are therefore entitled to receive health benefits under section B of this Article II, health benefits under Article III shall also be provided to any Employee who:

(1) (a) Has completed 20 years of credited service, including the required number of years of signatory service pursuant to Article IV C(6) of the 1974 Pension Plan or any corresponding paragraph of any successor 另外,

(b) 没有达到55岁，并且

(c) became disabled after December 6, 1974 while in classified 与雇主的雇佣关系

(d) is eligible for Social Security Disability Insurance Benefits under Title II of the Social Security Act or its successor;

第三条A. 雇主福利计划第(10)(e)条规定:

第三条福利待遇

A. 健康的好处

(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 保险单或其他医疗计划. 哪里有争议 between the carriers, the Plan shall, subject to provisions 1 and 2 immediately below, pay for such covered expenses but only as a convenience to the Beneficiary eligible for benefits under the Plan and only upon receipt of an appropriate indemnification or subrogation 协议; but the primary and ultimate responsibility for payment shall 留在另一方或承运人.

Obligations to pay benefits on behalf of any beneficiary shall be 条件:

1. upon such Beneficiary taking all steps necessary or desirable to recover the costs thereof from any third party 因此，谁有义务

2. upon such beneficiary executing such documents as are reasonably required by the Plan Administrator, including, but not limited to, an assignment of rights to receive such third party payments, in order to protect and perfect the Plan’s right to 任何此类第三方的报销.

讨论

受托人在这件事上陷入僵局. Trustees Holland and Hudson found for the Complainant. Trustees Dunham and 西格尔 found for the Respondent. Under the ROD procedures adopted pursuant to the 2002 NBCWA, the matter was referred to a neutral interest arbitrator, 罗伯特·纳格尔, 解决. The arbitrator was directed to choose one of the two draft opinions proposed by the Trustees. The arbitrator’s choice is printed below as the opinion of the Trustees.

仲裁员的决定

The 雇主 is not required to cover any of the medical expenses incurred by the Complainant as a result of his injury on 7月5日, 1997, because all expenses were covered by the Complainant’s own insurance policy.