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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: 81-710——1987年9月30日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald R. 皮尔斯,小.,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan 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 payment of benefits for medical services under the terms of the 雇主 Benefit Plan when a claim for payment was resubmitted to the 雇主 more than 33 months after being denied initially.

背景事实

该雇员受雇于J. 曼宁 & Associates Inc .). (曼宁) from May 1982 through September 1984. The 员工 received various physician services for a variety of conditions from a hospital outpatient department between July 10, 1982年和7月7日, 1983. The 员工 submitted the claims to 曼宁’s insurance carrier and was denied coverage for the claims on July 21, 1983. The reason for the denial is not known and the 员工 did not immediately appeal the decision.

In May 1986, the hospital brought a lawsuit against the 员工 for the amounts denied in July 1983. The 员工 then sought to have the claims paid by his current 雇主, A&C运输(A)&C)，它拒绝这样做.

In its response to the 员工’s ROD request, A&C did not contend that it is not obligated to provide coverage for expenses incurred while the 员工 was employed by J. 曼宁 & Associates but has stated that coverage of these claims was denied because of the length of elapsed time between the original denial of the claims (July 1983) and the resubmission of the claims to the 雇主 after the 员工 was sued by the provider (May 1986).

争端

Is the 雇主 responsible for payment of benefits for services when the claim was originally denied by the insurance carrier and was not resubmitted for nearly three years?

双方立场

Position of the 员工: The 雇主 is responsible for payment of benefits for covered medical services.

Position of the 雇主: The 雇主 is not responsible for payment of benefits because the employee did not resubmit the claim for nearly three years after original denial.

相关的规定

第三条. A. (10)(b) of the 雇主 Benefit Plan states in part:

(b) 政府

The Plan Administrator is authorized to promulgate rules and regulations to implement and administer the Plan, and such rules and regulations shall be binding upon all persons dealing with the Beneficiaries claiming benefits under this Plan.

讨论

The specific dispute in this case is whether the 雇主 may deny payment of benefits for services covered under the 雇主 Benefit Plan when the insurance carrier’s denial of such services was not appealed to the 雇主 until thirty-three (33) months after that denial.

The Trustees ruled in ROD 81-697 (copy enclosed) that under 第三条. A. (10)(b), the Plan Administrator is authorized to promulgate rules for administration of the Plan, as long as there is adequate advance communication of such rules through written notice such as publication in the sum description. 在这种情况下, the 雇主’s Summary Plan Description Summary Plan (SPD) contains a section on claims submission procedures (a copy of which is enclosed) which stipulates that “proof of loss must be furnished to the Insurance Company within ninety (90) days following the date of loss.” However, the SPD mentions nothing about a time limit for appeal of denied claims. The 雇主 has stated that 员工s were orally instructed that any claims denied by the carrier should be forwarded to the 雇主 for payment. Because no time limit for appeal of denied claims was promulgated in accordance with 第三条. A. (10)(b), none is therefore binding in this instance.

受托人的意见

The 雇主 is responsible for paying benefits for covered services provided to the 员工 from June 10, 1982年至6月7日, 1983.