November 1, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-326
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 now have the authority to resolve disputes involving excessive fees 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 $220.00 of the $4620.00 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. Therefore, the Employer is not obligated to pay the portion of the charge denied as excessive.
The Trustees note that the Employer and the UMWA have jointly agreed to help shield the beneficiary against providers who attempt to collect excessive charges.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee