OPINION OF TRUSTEES
ROD Case No: 11-0109 – March 25, 2015
Trustees: Michael H. Holland, Marty D. Hudson, Michael O. McKown, and
Joseph R. Reschini
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
The Complainant is a retiree of the Respondent and is receiving Social Security Disability Insurance benefits. He enrolled in Medicare Part A effective November 1, 2009, but did not enroll in Medicare Part B until June 1, 2011. Complainant received a flu vaccine on January 26, 2011, when he was eligible for, but not enrolled in, Medicare Part B. Respondent originally processed the charges in error as a Workers Compensation claim, but later reprocessed the charges. Respondent paid 100% of the allowable charge for the immunization and its administration and calculated its portion of the office visit charges as if the Complainant had been enrolled in Medicare Part B on the date of service. Respondent refuses to pay the portion of the office visit charges that Medicare Part B would have covered if Complainant had been enrolled in Medicare Part B on the date of service.
Who is responsible for the unpaid portion of the office visit charges?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: The Complainant failed to enroll in Medicare Part B as is required under the terms of the Employer Benefit Plan. The unpaid charges are the responsibility of the Complainant.
Article III.A(10)(d)(1) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(10) General Provisions
1. For Pensioners, and surviving spouses, the benefits provided under the Plan will not be paid to a Beneficiary otherwise eligible if such Beneficiary is eligible for Hospital Insurance coverage (Part A) of Medicare where a premium is not required and/or Medical Insurance coverage (Part B) of Medicare unless such Beneficiary is enrolled for each part of Medicare for which such Beneficiary is eligible. Any such Beneficiary who is enrolled in a Medicare program shall receive the benefits provided under the Plan only to the extent such benefits are not provided for under Medicare.
Article III.A(10)(d)(1) of the Employer Benefit Plan stipulates that the health benefits provided under the Plan will not be paid to a Beneficiary unless such Beneficiary is enrolled in each part of Medicare for which he is eligible. The Respondent provided enrollment data suggesting, and the Complainant confirmed, that the Complainant was not enrolled in Medicare Part B at the time
the disputed charges were incurred. Inasmuch as the Complainant was eligible for, but not enrolled in, Medicare Part B at the time the disputed charges were incurred, the Complainant is not entitled to the payment of the disputed charges by the Plan.
Opinion of the Trustees
The Respondent is not required to pay the disputed charges for January 26, 2011.