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受托人的意见
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在再保险
投诉: 下岗职工和退休人员
被申请人: 雇主
ROD案例编号: 98-045 - 2005年4月14日
受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰, 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
投诉人为被投诉人于三月十九日解雇的雇员, 2003, 以及在煤炭行业的最后签署雇主与答辩人在一起的退休人员. The Respondent is signatory to a 1998 National Bituminous Coal Wage Agreement (Wage Agreement) which terminates effective June 30, 2003. In November 2002, the Complainants began receiving notices of non-payment of their medical bills. 从那时起, the Complainants have received collection notices and statements from providers threatening collection action if the outstanding bills are not paid.
The Respondent is self-insured so that medical claims are submitted to a company that processes and pays the claims from funds provided by the Respondent. 根据答辩人, 由于财政困难, 承保的医疗索赔支付已经落后. 然而, the Respondent states that it anticipates financial assistance from another company and expects to bring the payments up to date. 根据处理被告医疗索赔的公司, 截至4月22日, 2003, 医疗索赔已支付至10月31日, 2002.
争端
Is the Respondent providing health benefits coverage for the Complainants as required under the Wage Agreement and 雇主 Benefit Plan?
双方立场
Position of the 投诉: The Respondent is required to pay in a timely manner the covered medical expenses incurred by the Complainants and their eligible dependents.
被访者立场:由于经济困难, 承保的医疗索赔付款已经落后. 然而, with anticipated financial assistance, payment of claims should be brought up to date.
相关的规定
Article XX (c)(3)(i) of the National Bituminous Coal Wage Agreement of 1998 provides in pertinent part:
(3)(i) Each signatory 雇主 shall establish and maintain an Employee benefit plan to provide, 通过保险公司实施, health and other non-pension benefits for its Employees covered by this Agreement as well as pensioners, 1974年养恤金计划和信托皇冠搏彩中心网站, 谁的最后一个签署人曾受雇于该雇主. 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.
雇主福利计划第I(1)、(2)、(4)和(5)条规定:
第一条-定义
下列术语具有本协议规定的含义:
(1) “雇主”指(雇主名称).
(2) “工资协议”指1998年全国烟煤工资协议, 如不时修订及任何后续协议.
(4) “雇员”系指为雇主从事保密工作的人员, 有资格获得本协议项下的福利.
(5) “养老金领取者”系指领取养老金的任何人, 除了(i)基于少于20年信用服务的递延既得退休金, or (ii) a pension based in whole or in part on years of service credited under the terms of Article II G of the 1974 Pension Plan, 或其任何继承者的任何相应段落, 根据1974年退休金计划(或其任何后续计划), 谁的最后一次机密签署工作是在雇主处, subject to the provisions of 第二条乙 of this Plan; or (iii) a special permanent layoff pension under the terms of Article II. E (4) of the 1974 Pension Plan, during any period prior to the person’s attainment of age 55. “Pensioner” shall not mean any individual entitled to benefits under section 9711 of the Internal Revenue Code of 1986, 根据1992年《皇冠搏彩中心网站》修订.
第二条乙. 1998年雇主福利计划第(1)条规定:
第二条-资格
The persons eligible to receive the health benefits pursuant to Article III are as follows:
B. 养老金领取者
根据本办法第三条，养恤金领取人的健康津贴如下:
(1) 任何退休金领取者，在
(a) 根据1974年养恤金计划领取养恤金者的最初退休日期;及
(b) 12月31日, 1997, 都有资格作为养老金领取者享受以下的保险, 并受本计划所有其他条款的约束. 尽管本计划第i(5)条对退休金领取人的定义有(i)及(ii)项规定, any such Pensioner who was eligible for benefits under the 1974 Benefit Plan as a Pensioner on December 5, 1977, 都有资格享受这些福利, 受本计划所有其他条文规限.
第三条D. (1)雇主福利计划(a)的相关部分规定:
第三条-福利
D. 一般规定
(1) 续保
(a) 裁员
如果雇员因裁员而停止工作, 健康的延续, 人寿、意外死亡和肢解保险的保险范围如下:
工作时数
24 .雇主
连续日历月
紧接前一时期 保险期限
雇员入职日期 继续
最后的工作 最近工作日期
2000小时以上 月加余额
12个月
500或更多，但少于 月加余额
2000小时 6个月
少于500小时 30天
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 通过保险公司实施, 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.
第二条乙. establishes that an individual who is eligible for pension benefits under the 1974 Pension Plan is eligible for health benefits under the 雇主 Benefit Plan. 第三条D. (1) (a) of the 雇主 Benefit Plan provides continued benefits coverage for laid-off Employees based upon the number of hours worked for the 雇主 during the 24-month period immediately prior to the date last worked.
The Complainants in this case have received collection notices from health providers because the Respondent has failed to pay the Complainants’ medical bills in a timely manner. 在ROD 88-492, the Trustees addressed the issue of processing claims in a timely manner and found that the time taken by the 雇主 or its agent to process and pay undisputed health benefit claims should not cause collection action to be taken against the beneficiary, 不得导致损害受益人信誉的任何其他行为. The Trustees also noted that the 雇主 must insulate and defend the beneficiary against any such actions initiated by the provider(s). 因此, the Trustees conclude that in this case the Respondent’s failure to process undisputed health benefits claims for the Complainants in a timely manner and its claim that it is financially unable to process existing health benefits claims does not conform to the requirements of the Wage Agreement or the 雇主 Benefit Plan nor relieve the Respondent from its obligation to provide appropriate coverage.
受托人的意见
The Respondent’s failure to process undisputed health benefits claims for the Complainants in a timely manner does not conform to the requirements of the Wage Agreement of 1998 or the 雇主 Benefit Plan. The Respondent’s claim of financial difficulty does not relieve it of its obligation to provide coverage. The Respondent must insulate and defend the Complainants against any actions initiated by the provider(s).