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受托人的意见
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在再保险
投诉:养老金领取者
被申请人:雇主
ROD Case No: CA-040 – 二零零三年九月十七日
受托人 : 一个. 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.
受托人审查了有关根据《官方网站》第9711条维持的1992年《皇冠搏彩中心》(《皇冠搏彩中心网站》)雇主福利计划条款提供福利的争议的事实和情况.
背景事实
The Complainants are Pensioners who are eligible to receive health benefits coverage from the Respondent. 申诉人的代表声称，答辩人执行的福利计划没有提供《皇冠搏彩中心网站》雇主福利计划条款规定水平的健康福利. 具体地说, 申诉人的代表说，申诉人的医疗索赔没有得到全额支付，因为答辩人认定收费过高, but the Respondent has refused to hold the Complainants “harmless” for the excessive charges. As a result, the Complainants’ bills have been turned over for collection. 除了, the Complainants’ representative states that the Respondent does not pay the medical claims in a timely manner.
答辩人指出，超过合理和惯例金额的承保福利费用不包括在雇主福利计划的承保范围内，并引用ROD 29作为其立场的支持. 答辩人说，它按美国健康保险协会(HIAA)第85百分位数支付医疗索赔. 被投诉人还指出，许多未解决的索赔是由于投诉人的索赔文件不充分，并且未能在被要求时提供额外的文件. 最后, 答辩人指出，符合医疗保险资格的退休人员应首先向医疗保险提交医疗索赔，然后再向答辩人提交. 答辩人说，有关所涉医疗索赔的文件并没有表明医疗保险首先收费.
争端
被投诉人是否按照《皇冠搏彩中心网站》雇主福利计划的要求为投诉人提供健康福利?
双方立场
Position of the Complainants: The Respondent is required to apply the “hold harmless” provisions of 第三条. A. (10) (g) when medical charges exceed the reasonable and customary amounts for covered services. The Respondent is also required to pay in a timely manner the covered medical expenses incurred by the Complainants.
被投诉人的立场:被投诉人不需要根据《皇冠搏彩中心网站》雇主福利计划提供超过合理和习惯的服务费用的保险. The Respondent states its position is supported by the Trustees’ decision in ROD 29. 申诉人的医疗索赔应先提交给联邦医疗保险，然后再提交给被告的保险公司.
相关的规定
第三条. A. (10) (g) 1. 和3. of the Coal Act Employer Benefit Plan provide:
第三条福利待遇
A. 健康的好处
(10) 一般规定
(g) Explanation of Benefits (EOB), Cost Containment and
持有无害的
1. Each Beneficiary shall receive an explanation of billing and payment rendered on behalf of such Beneficiary. 是否应因计划管理人认定收费超过合理和惯例收费而拒绝支付服务的全额费用, a copy of such EOB shall be forwarded to the UMWA (International Headquarters, 注意事项:福利部).
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3. 雇主和妇女协会一致认为，收费过高和保健费用不断上涨是一个共同问题，需要双方共同努力加以解决. 在任何情况下，提供者试图收取过高的费用或对医疗上不必要的服务收取费用, 如计划所界定, 来自受益人, the Plan Administrator or his agent shall, with the written consent of the Beneficiary, 试着解决这个问题, either by negotiating a resolution or defending any legal action commenced by the provider. 计划管理人或其代理人是否代表受益人协商事项的解决方案或为法律诉讼进行辩护, the Beneficiary shall not be responsible for any legal fees, 定居点, judgments or other expenses in connection with the case, but may be liable for any services of the provider which are not provided under the Plan. The Plan Administrator or his agent shall have sole control over the conduct of the defense, including the determination of whether the claim should be settled or an adverse determination should be appealed.
第四条. B. of the Coal Act Employer Benefit Plan provides:
ARTICLE IV MANAGED CARE, COST CONTAINMENT
B. 除了, the Employer may implement certain other managed care and cost containment rules, 可同时适用于PPL提供者和非PPL来源提供的福利，但(除计划中特别规定的共同付款外)不会导致福利减少或计划下提供的承保服务的额外费用.
讨论
In accordance with 第三条A. (10)(g) of the Coal Act Employer Benefit Plan, 计划管理人可决定承保医疗服务的收费是否超过提供该服务地区的合理和习惯收费. If the charge for a covered service is not excessive, the Employer is responsible for payment of the charge under the terms of the Employer Benefit Plan. If a charge for a covered service is determined to be excessive, 计划管理人应尝试解决该问题，或为养老金领取人辩护，反对试图收取此类费用的提供者. Whether the Employer negotiates a resolution or defends a legal action, the Pensioner would not be responsible for any legal fees, 定居点, judgments or other expenses in connection with the case, but may be liable for any services of the provider which are not provided under the Plan. 第三条A. (10)(g) 3. is known as the Plan’s “hold harmless” provision. Additionally, pursuant to 第四条 B. of the Coal Act Employer Benefit Plan, no reduction of benefits or additional costs for covered services shall be suffered by beneficiaries.
在这种情况下, 被投诉人按HIAA第85百分位数支付索赔，并拒绝支付超过最高允许支付的费用. 关于支付应付余款的催收通知表明提供商曾试图向投诉人收取这些超额费用. The Complainants have requested that the Respondent initiate hold harmless procedures; therefore, the Respondent is required to follow the “hold harmless” provision of 第三条A. (10) (g) of the Coal Act Employer Benefit Plan.
The Respondent cited ROD 29 to support its position. 在ROD 29中, 受托人发现雇主不需要为被认为过高的费用提供保险. ROD 29是根据1978年全国烟煤工资协议(工资协议)进行审查的，该协议不包含“保持无害”条款. However, the 1984 Wage Agreement was amended to include the “hold harmless” provision. 因此, ROD 29 did not address the “hold harmless” provision found under subsequent Wage Agreements. In later opinions (see RODs 84-412 and 88-625) which address the “hold harmless” provision under 第三条A. (10) (g) of the Employer Benefit Plan, 受托人认为，当确定收费过高或用于医疗上不需要的服务时，雇主必须遵守"保持无害"规定.
The Complainants state that the Respondent does not pay the medical claims in a timely manner. 尽管《皇冠搏彩中心网站》雇主福利计划没有规定处理和支付医疗索赔的时间期限, a reasonable payment period may be inferred. 行业惯例和大多数州规定的期限要求表明，处理和支付索赔(包括处理所需的所有文件)的合理范围是15至60天(见RODS 88-492和88-633)。. 被投诉人声称，没有及时支付索赔是由于投诉人没有提交足够的文件来处理索赔，或者因为索赔没有首先提交给医疗保险. The Respondent’s insurance carrier provided information on a sampling of the claims sent in by the Pensioners. Once the insurance carrier received the claims, the claims were paid within an 11 day period. 因此, 被申请人的保险公司审查和支付索赔样本的期限不超过15至60天.
受托人的意见
The Respondent is required to follow the “hold harmless” provision of 第三条. A. (10)(g) of the Plan when a charge has been determined to be either excessive or for services not medically necessary.