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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: 98-041 - 2003年9月17日
受托人: A. 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 雇主 Benefit Plan.
背景事实
The Complainant is an active mine worker who has been employed in a classified position with the Respondent since 1979. 申诉人有一个儿子，出生日期是4月13日, 1980, 与投诉人同住. The Complainant has requested health benefits coverage for his son as a disabled adult under the Respondent’s 雇主 Benefit Plan.
8月15日来信, 2002, the Complainant’s son’s physician stated that the Complainant’s son was born with Meningomyelocele (the bones of the spine do not completely form and the spinal canal is incomplete) with associated Hydrocephalus (abnormal buildup of fluid in the brain), Neurogenic Bladder (problem with the muscles and nerves that hold and release urine in the bladder) and Paraplegia (paralysis of the lower half of the body). The physician also stated that the Complainant’s son has had several complications from his condition such as Tethered Spinal Cord which caused weakness of his lower extremities and required surgery. The physician noted that the Complainant’s son is not able to live independently and is dependent upon his parents for support and care.
根据社会保障局的说法, the Complainant’s son has been receiving Supple精神 Security Income since October 1, 1984.
The Complainant’s son was covered as a dependent under the Respondent’s 雇主 Benefit Plan until he attained age 22. Subsequently, the Respondent denied coverage for the Complainant’s son as a disabled adult.
争端
Is the Complainant’s son eligible for health benefits coverage as a disabled adult under the terms of the 雇主 Benefit Plan?
双方立场
Position of the 原告: The Complainant’s son is eligible for health benefits coverage as a disabled adult under the terms of the 雇主 Benefit Plan because the Complainant’s son has been chronically disabled since birth and he is totally dependent upon the Complainant for support.
Position of the 被申请人: The Complainant’s son is not eligible for health benefits coverage as a disabled adult under the terms of the 雇主 Benefit Plan because based on a medical rating used by the Respondent’s insurance carrier, 申诉人的儿子不被视为完全残疾.
相关的规定
第二条D. 1998年雇主福利计划第(2)及(5)条规定:
第二条资格
The persons eligible to receive the health benefits pursuant to Article III are as follows:
D. 合格的家属
Health benefits under Article III shall be provided to the following members of the family of any 员工, 养老金领取者, 或根据A段领取健康福利的残疾雇员, B, 或本条第2款(C)项:
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(2) Unmarried dependent children of an eligible 员工 or 养老金领取者 who have not attained age 22;
(5) 受养子女(任何年龄)、合资格雇员、领取退休金者或 配偶，智障人士或残疾人士之前 年满22岁，这种残疾是持续的，要么生活在 与该雇员或领取退休金者同住一个家庭，或被限制在 照料或治疗机构. 这类儿童的健康福利将得到保障 只要在世的父母有资格享受健康福利，就继续.
就本D段而言，一个人应被视为依赖于 eligible 员工, 养老金领取者 or spouse if such 员工, 养老金领取者 or spouse provides 在定期的基础上超过一半的支持给这样的人.
问题与回答(Q&A) H-6(81)(第1部分)规定:
主题: HEALTH BENEFITS; Disabled Children H-6 (81)
Reference: (50B) II C(5), II D; (74B) II C(5), II D
问题:
Certain dependent children (of any age) are eligible for health benefits if they are 精神ly retarded or become disabled prior to attaining age 22 and such disability is continuous.
(1) What is the standard for determining whether the dependent child is “精神ly retarded or disabled”?
答:
(1) 如果一个人有任何职业上的障碍，那么他就是“智力迟钝或残疾”
可测物理, 精神, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.
讨论
第二条D. (5)雇主福利计划 stipulates that health benefits coverage will be provided to dependent children of any age who are 精神ly retarded or who become disabled prior to attaining age 22, 残疾是持续的. Q&A H-6 (81) provides that “a person is 精神ly retarded or disabled if the person has any professionally 可测物理, 精神, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.”
申诉人的儿子在22岁之前残疾. His disability is continuous, and he has never lived independently of his parents. 据申诉人儿子的医生说, the Complainant’s son is not able to live independently and is dependent upon his parents for support and care. 除了, the Complainant’s son has been awarded Supple精神 Security Income (“SSI”) benefits based on a disability. 根据社会保障法, an individual is considered disabled if “he is unable to engage in any substantial gainful activity by reason of any medically 可测物理 or 精神 impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” (42U.S.C. §1382c (3)(A).
The Respondent argues that the Complainant’s son is ineligible because its insurance carrier’s medical department determined that his disability rating, 申诉人儿子的医生转述, 小于11, 这表明申诉人的儿子并非完全残疾. 这个结论, 然而, is refuted by the Complainant’s son’s physician in other evidence provided to the Respondent and by the award of Social Security benefits. 相应的, the Complainant’s son is eligible for health benefits coverage as a disabled adult because he has a 可测物理 impairment which is considered continuous and which precludes his living or functioning independently of his parents.
受托人的意见
The Respondent is required to provide health benefits coverage for the Complainant’s son as a disabled adult dependent subject to the requirements of 第二条D. (5)雇主福利计划.