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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: 81-375——1984年2月10日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 1950 Benefit 计划 and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the conversion of benefits coverage for a laid-off 员工 under the terms of the 雇主’s Benefit 计划 and hereby render their opinion on the matter.

背景事实

The Complainant was employed by the Respondent for several years prior to being laid-off on May 16, 1982. During the 24 consecutive calendar month period immediately prior to his date last worked, 投诉人工作时间超过2小时,被投诉人有000小时的时间, qualifying him for continued health benefit coverage through May 31, 1983, 他收到了.

At the expiration of his period of eligibility, the Complainant exercised his option to 转换 his insurance coverage and paid the $620 premium for a three month period to the insurance carrier within the 31 day conversion period.

此后不久, the Complainant’s wife incurred hills for services related to pregnancy, She was advised by the insurance carrier that the 转换ed policy did not provide the same level of coverage as previously provided under the 雇主’s Benefit 计划 and, 具体地说, that services related to pregnancy were not equally covered. 投诉人声称 that $9,952,80 of the total charges has not been paid by the 转换ed plan,

Because the Complainant had not submitted the matter to the 计划 Administrator for a final decision prior to requesting resolution by the Trustees, 有, 从技术上讲, no dispute for the Trustees to consider, 不过, when the Funds referred the issue to the 计划 Administrator for consideration, he chose to deny coverage for the claims in question and to respond to the Trustees regarding the Resolution of 争端 request. 结果是, a bona fide dispute existed and the issue is considered for resolution based on the preceding facts.

争端

Is the coverage provided under the individual conversion privilege required to be similar to that under the 雇主’s Benefit 计划? Is the Respondent responsible for payment of the outstanding charges not paid by the conversion plan?

各方立场

Position of the 原告: Coverage provided under the conversion privilege should be similar to that provided under the 雇主’s Benefit 计划.

Position of the 被申请人: The Complainant was informed of the conversion privilege prior to his termination of continuation of coverage. He was advised that the private plan would not provide the same level of benefits coverage as the 雇主’s Benefit 计划. Since the charges were incurred on or after July 25, 1983 and the Complainant’s eligibility for continuation of coverage had ended May 31, 1983, this dispute is only applicable in relation to his eligibility for coverage.

相关的规定

第三条D. (3) (b) of the 雇主’s Benefit 计划 provides:

(b) When health benefits coverage terminates, 受益人可以, 在应用程序, 转换, 未经体检, to a policy issued by the insurance carrier provided such application is made to the insurance Carrier within 31 days after the coverage terminates. 保单类型, coverage and–premiums therefore are subject to the terms and conditions set forth by the insurance carrier.

讨论

第三条D. (3) (b) of the 雇主’s Benefit 计划 provides that 受益人可以 转换 to a policy issued by the insurance company if application is made within the specified time limits, The Complainant was provided with and exercised his conversion option within that time period.

投诉人声称, 然而, that the policy issued by the insurance carrier was inconsistent with that provided under the 雇主’s Benefit, 计划. While this was in fact the case, 第三条D. (3) (b) of the 雇主’s Benefit 计划 clearly specifies that the type of policy, coverage and premiums offered by the insurance carrier at the time of conversion are subject to the terms and conditions set forth by the insurance carrier. There is no requirement that coverage be the same as that provided under the 雇主’s Benefit 计划. 因此, 被申请人的义务, 作为前雇主, were met by virtue of its making available a plan for conversion.
受托人的意见

The Respondent has complied with its contractual obligations and is not responsible for the payment of charges incurred after the expiration of the Complainant’s eligibility under the 雇主 s Benefit 计划.