April 19, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-184
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Advisory Opinion concerning the level of health benefits coverage for surgical services for your spouse.
Under Article III A. (11)(a) 12. of the Employer’s Benefit Plan, the Plan Administrator has the sole authority to determine whether a charge is excessive. Under the exemption granted by the Department of Labor in April 1982, the Trustees have the authority to resolve disputes involving excessive fees only to the extent that they may determine whether the Plan Administrator has adopted and applied reasonable procedures calculated to arrive at an excessive fee determination.
In this case,, the Plan Administrator determined that $650.00 of the $3,000.00 total charge is excessive. Based on information submitted by the Employer, the Trustees are of the opinion that the Plan Administrator used reasonable procedures to arrive at an excessive fee determination and that these procedures are applied in this instance. Therefore, the Employer is not obligated to pay the portion of the charge denied as excessive.
Under provisions of the Employer Benefit Plan, the Employer and your Union Representative have an obligation to cooperate to help shield you against providers who attempt to collect excessive charges (Article III A. (10) (g)). While the Trustees do not require a standard course of action for the Plan Administrator and the Union Representative to follow, the Plan Administrator and the Union representative must assist the beneficiary in resisting payment of medical charges that the Plan Administrator has determined to be excessive. If a provider of hospital or medical services tries to collect this excessive fee from you, you should contact your Union Representative and your Employer to enlist their support.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee