对受托人的看法 ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Pensioner
Employer
11-0149 – March 28, 2018
Michael H. Holland, Marty D. Hudson, Michael O. McKown, and Joseph R. Reschini
受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.
Background Facts
投诉人是被投诉人的退休人员，并从被投诉人那里获得医疗保险以外的医疗福利.
申诉人于2016年11月接受了膝关节置换手术. 他于2016年11月1日至11月4日住院. 医疗保险A部分(医院保险)批准了索赔并支付了12 506美元.71 to the provider. Medicare did not pay $1,288.00, which was the Medicare Part A deductible for 2016. The Respondent denied payment of $1,288.00. 被投诉人声称，因为该金额是用于投诉人的免赔额, it is not a covered charge under the Employer Benefit Plan. 提供商向投诉人开具了账单，投诉人支付了1288美元.00.
没有医疗保险B部分(医疗保险)费用有争议.
Dispute
被投诉人是否需要支付投诉人的医疗保险A部分(医院保险)免赔额, which was $1,288.00 for 2016?
Positions of the Parties
投诉人的立场:这些费用属于雇主福利计划的承保福利. 被投诉人负责支付投诉人医疗保险A部分(医院保险)的免赔额, which was $1,288.00.
Opinion of Trustees ROD Case No. 11-0149 Page 2
被投诉人的立场:投诉人应对医疗保险免赔额负责, 哪些不是雇主福利计划所涵盖的福利.
Pertinent Provisions Article III A.(1)(a) of the Employer Benefit Plan states:
ARTICLE III BENEFITS A. Health Benefits
(1) Inpatient Hospital Benefits (a) Semi-private room
当受益人被持牌医生(以下简称“医生”)作为住院病人在认可医院(以下简称“医院”)接受治疗时。, 补助金将用于半私人房间住宿(包括特殊饮食和一般护理)以及医院为诊断和治疗受益人的病情而提供的下述所有医疗必要服务.
Article III A. (10) (d) and Article III.A.(10) (f)雇主福利计划第1条和第3条在相关部分规定:
ARTICLE III BENEFITS A. Health Benefits
(10) General Provisions (d) Medicare
1. For Pensioners, and surviving spouses, 如果受益人有资格享受医疗保险的医院保险(a部分)(无需支付保险费)和/或医疗保险的医疗保险(B部分)，则本计划项下提供的福利将不会支付给其他有资格的受益人，除非该受益人参加了其有资格享受的医疗保险的每个部分. 参加医疗保险计划的任何该等受益人，仅在医疗保险未提供该等福利的范围内，方可享受本计划提供的福利.
Opinion of Trustees ROD Case No. 11-0149 Page 3
(f) Non-Duplication
本计划提供的健康福利受以下不重复条款的约束:
1. 福利将被其他团体计划所提供的福利所减少，……..
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3. As used herein, "团体计划"指(i)将个人作为团体成员纳入保险范围，并通过团体保险提供住院或医疗福利或服务的任何计划.. . . .
Discussion
Article III A.雇主福利计划(1)(a)规定支付半私人病房住院津贴以及医院为治疗受益人的医疗状况而提供的所有必要医疗服务. Article III A. (10) (d)仅在有资格参加联邦医疗保险的受益人实际参加联邦医疗保险的情况下，才提供本计划项下的福利支付. The Plan will pay benefits under the Plan, for enrolled beneficiaries, 只是在医疗保险不提供这些福利的范围内.
The Complainant, a retiree who is enrolled in Medicare Part A and Part B, received knee replacement surgery in November 2016. 申诉人的手术费和住院费已提交医疗保险, his primary insurance coverage. 医疗保险将费用降低到允许的数额，支付了12506美元.71 to the provider. Medicare did not pay $1,288.这是申诉人2016年医疗保险A部分(医院保险)的免赔额.
The Respondent denied the $1,288.00 charge, 声称因为这是申诉人的免赔额, it was not a covered benefit under the Plan. The Complainant paid the provider $1,288.00, on his personal credit card in January 2017.
Since the Complainant is enrolled in the Medicare program, as required by the Employer Plan, 他有权享受医疗保险所涵盖服务的福利, his primary insurance, does not pay. In this case, 申诉人住院接受膝关节置换手术, which is a covered benefit under the Employer Plan. 医疗保险为1 288美元之后发生的所有住院费用提供福利.00 deductible was applied. This is a deductible that the Medicare program imposes. The Employer Benefit Plan does not have such a deductible. Rather, 雇主福利计划要求将申诉人的全部住院费用作为承保福利支付，而不考虑医疗保险的免赔额. Thus, the $1,288.00, 免赔额是雇主计划所涵盖的福利，因为它是由雇主计划所涵盖的服务产生的，而不是由医疗保险支付的.
Opinion of Trustees ROD Case No. 11-0149 Page 4
There is no duplication of benefits in this case, 因为免赔额是雇主计划的承保范围，而不是医疗保险. Therefore, 雇主负责为投诉人的A部分(医院保险)免赔额提供福利, which was $1,288.00 for 2016.
受托人曾在ROD CA-031中就此问题发表意见. 该意见指出，住院费用的免赔额是雇主计划所涵盖的福利，并认为雇主有责任支付医疗保险a部分的免赔额.
Opinion of the Trustees
Pursuant to Article III A.(1)(a) and Article III A. (10) (d) of the Employer Benefit Plan, 受益人的医疗保险a部分(医院保险)免赔额是本计划涵盖的福利. 被投诉人负责支付投诉人医疗保险A部分(医院保险)的免赔额, which was $1,288.00 for 2016.