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OPINION OF TRUSTEES
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 98-011 – September 13, 2000
受托人: A. Frank Dunham, Michael H. 霍兰德，马蒂·D. 哈德逊和
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 of the 雇主 Benefit Plan.
Background Facts
The Complainant is eligible for health benefits coverage from the Respondent as an active 员工. The Complainant has requested coverage for two dependent children. The children are related to the Complainant’s spouse through the following history. The Complainant’s spouse gave birth to a male child. Later, the child was adopted by the Complainant’s spouse’s parents–the child’s grandparents. 随后, the child grew up, married and had two male children–one born in 1983 and the other in 1989. The two children have been living with the Complainant and his spouse since May 1998. The married child gave the Complainant and his spouse legal guardianship of his two children. The Complainant states that the Respondent should provide coverage for the two children because the Complainant has provided all of their support since May 1998.
争端
Is the Respondent required to provide coverage for the two dependent children?
Positions of the Parties
Position of the 原告: The Respondent is required to provide health benefits to the two children because the Complainant has legal guardianship and had been providing all of the children’s support since May 1998.
Position of the 被申请人: The Respondent is not required to provide coverage for the two children because the Complainant’s spouse’s son was adopted by her parents; thus, the two children in question are not the legal stepsons or step grandchildren of the Complainant.
Pertinent Provisions
篇文章中,我. (1), (2), (4), and (7) of the 雇主 Benefit Plan provides:
篇文章中,我 – Definitions
The following terms shall have the meanings herein set forth:
(1) “雇主” means (雇主’s Name)
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1998, as amended from time to time and any successor agreement.
(4) “员工” shall mean a person working in a classified job for the 雇主, eligible to receive benefits hereunder.
(7) “Dependent” shall mean any person described in Section D of 篇文章中,我I 本.
Pertinent Provisions
篇文章中,我 (1), (2), (4) and (7) of the 雇主 Benefit Plan provide:
篇文章中,我 – Definitions
The following terms shall have the meanings herein set forth:
(1) “雇主” means (雇主’s Name).
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1988, as amended from time to time and any successor agreement.
(4) “员工” shall mean a person working in a classified job for the 雇主, eligible to receive benefits hereunder.
(7) “Dependent” shall mean any person described in Section D of 篇文章中,我I 本.
第二条D. (2) of the 雇主 Benefit Plan provides:
篇文章中,我I – Eligibility
The persons eligible to receive the health benefits pursuant to 篇文章中,我II are as follows:
D. Eligible Dependents
Health benefits under 篇文章中,我II shall be provided to the following members of the family of any 员工, 养老金领取者, or disabled 员工 receiving health benefits pursuant to paragraphs A, B, or C of this 篇文章中,我I:
(1) A spouse who is living with or being supported by an eligible 员工 or 养老金领取者;
(2) Unmarried dependent children of an eligible 员工 or 养老金领取者 who have not attained age 22;
(3) A parent of an eligible 员工, 养老金领取者 or spouse, if the parent has been dependent upon and living in the same household (residence) with the eligible 员工 or 养老金领取者 for a continuous period of at least one year;
(4) Unmarried dependent grandchildren of an eligible 员工, 养老金领取者 or spouse who have not attained age 22 and are living in the same household (residence) with such 员工 or 养老金领取者;
(5) Dependent children (of any age), of an eligible 员工, 养老金领取者 or spouse, who are mentally retarded or who become disabled prior to attaining age 22 and such disability is continuous and are either living in the same household with such 员工 or 养老金领取者 or are confined to an institution for care or treatment. Health benefits for such children will continue as long as a surviving parent is eligible for health benefits.
For purposes of this paragraph D, a person shall be considered dependent upon an eligible 员工, 养老金领取者 or spouse if such 员工, 养老金领取者 or spouse provides on a regular basis over one-half of the support to such person.
Question and Answer (Q&A) H-3 (81) states:
主题: 健康的好处; Dependent Children
Reference: (SOB) II C; (74B) II C
问题:
Assuming all elements of dependency are met, may the following relatives qualify for health benefits as dependents of participants?
(1) Stepchildren, illegitimate children and adopted children
(2) 孙子
(3) Nieces, nephews, foster children, brothers and sisters
答:
(1) Stepchildren, illegitimate children and adopted children are covered for health benefits. Coverage for adopted children begins the date they begin living in the participant’s household, provided the adoption process has begun.
(2) 孙子 are covered provided they are living in the same household as the participant. Their eligibility terminates upon the death of such participant; they are not included for health benefits as the dependent of a surviving spouse.
(3) Nieces, nephews, foster children, brothers and sisters are not covered. They may be included, however, if adopted by the participant.
讨论
Under 篇文章中,我I. D. of the 雇主 Benefit Plan, health benefits are provided to certain dependent family members of an 员工. Assuming all elements of dependency are met, Q&A H-3 (81) further clarifies what relatives are covered under the 雇主 Benefit Plan. The first step in this case, 因此, is to define the relationship between the 员工–the Complainant–and the two children in question.
When the Complainant’s spouse’s parents adopted the Complainant’s spouse’s child, her son legally became her brother. Thus, the relationship of the Complainant’s spouse to her brother’s children is that of an aunt. Therefore, the Complainant’s relationship to the children is that of an uncle.
The issue of an 员工’s niece’s eligibility for health benefits coverage has previously been addressed by the Trustees in RODs 84-209, 88-282, 和88 - 629. The 员工s in each of these cases had legal guardianship for the niece and were providing all of the niece’s support. 在每种情况下, the Trustees concluded that the niece of an 员工 does not qualify for health benefits unless the child is adopted by the 员工. An arrangement of legal guardianship is not equivalent to the process of adoption.
The Complainant in this case has not initiated adoption proceedings. 相应的, the Respondent is not required to provide health benefits coverage for the Complainant’s nephews.
Opinion of the Trustees
The Respondent is not required to provide health benefits coverage for the Complainant’s nephews under the terms of the 雇主 Benefit Plan.