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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:98-031 - 2002年2月19日
受托人:. 弗兰克·邓纳姆，迈克尔·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.
背景事实
原告 has been employed in a classified position with the Respondent since
1995年9月. The Respondent is signatory to the 1998 National Bituminous Coal Wage
1998年《工资协议. According to the 发牢骚的人, in October 2000 the
发牢骚的人 began receiving notices of non-payment of his medical bills. 原告
brought the matter to the attention of his Plan Administrator who indicated to the 发牢骚的人
that the unpaid medical bills would be paid. However, the 发牢骚的人 states that since that
conversation, the Respondent has paid some of his bills but others remain unpaid. 因此，
the 发牢骚的人 has received two collection notices and statements from providers threatening
collection action if the outstanding bills are not paid.
争端
Is the Respondent providing health benefits coverage for the 发牢骚的人 and his eligible
dependants as required under the National Wage Agreement and 雇主 Benefit Plan?
双方立场
Position of the 发牢骚的人: The Respondent is required to pay the covered medical expenses
incurred by the 发牢骚的人 and his eligible dependents in a timely manner.
Position of the Respondent: The Respondent has not replied to repeated correspondence from
Funds’ staff requesting its position in this dispute.
受托人的意见
连杆箱编号. 98-031
第二页
相关的规定
Article XX (c)(3)(i) of the National Bituminous Coal Wage Agreement of 1998 provides in
相关的部分:
(3)(i) Each signatory 雇主 shall establish and maintain an Employee benefit
计划提供, implemented through an insurance carrier(s), health and other nonpension benefits for its Employees covered by this Agreement as well as pensioners,
under the 1974 Pension Plan and Trust, whose last signatory classified employment was
与该雇主. The benefits provided by the 雇主 to its eligible Participants
pursuant to such plans shall be guaranteed during the term of this Agreement by that
雇主 at levels set forth in such plans.
Article I (1), (2) and (4) of the 雇主 Benefit Plan provide:
第一条-定义
The following terms shall have the meanings herein set forth:
(1)“雇主”指(雇主名称).
(2) “Wage Agreement” means the National Bituminous Coal Wage
Agreement of 1998, 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A款. (4) of the 雇主 Benefit Plan provides:
第二条-资格
The persons eligible to receive the health benefits pursuant to 第二条I are as follows:
A. 积极的员工
(4) A new Employee will be eligible for health benefits from the first
我为雇主工作了一天.
受托人的意见
连杆箱编号. 98-031
第3页
讨论
Article XX (c)(3)(i) of the 1998 Wage Agreement requires an 雇主 to provide an 雇主
Benefit Plan that is implemented through an insurance carrier(s), 用于医疗和其他非养老金福利. It further requires that benefits provided by the 雇主 to its eligible
Participants pursuant to such plans shall be guaranteed during the term of this Agreement by that
雇主 at levels set forth in such plans. 第二条. 雇主福利计划A条规定
health benefits coverage to active employees working in classified jobs for a signatory
雇主.
原告 in this case has received collection notices because the Respondent has failed
to pay the 发牢骚的人’s medical bills in a timely manner. 在ROD 88-492中，受托人
addressed the issue of processing claims in a timely manner and found that the processing time
taken by the 雇主 or its agent to adjudicate health benefit claims may not cause collection
action to be taken against the beneficiary nor result in any other action that would impair the
受益人的信誉. The Trustees also noted that the 雇主 must insulate and
defend the beneficiary against any such 由提供者发起的操作. 因此,
Trustees conclude that in this case the Respondent’s failure to process health benefits claims for
the 发牢骚的人 in a timely manner does not conform to the requirements of the National
Bituminous Coal Wage Agreement or the 雇主 Benefit Plan.
受托人的意见
The Respondent’s failure to process health benefits claims for the 发牢骚的人 in a timely
manner does not conform to the requirements of the National Bituminous Coal Wage Agreement
或雇主福利计划. The processing time taken by the Respondent or its agent
to adjudicate health benefit claims may not cause collection action to be taken against the
发牢骚的人 nor result in any other action that would impair the creditworthiness of the
发牢骚的人. The Respondent must insulate and defend the 发牢骚的人 against any such
由提供者发起的操作.