June 25, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-566
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 Resolution of Dispute concerning the level of health benefits coverage for surgical services for your spouse.
Under Article III. A. (11) (a) (12) of the Employer 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 were given 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 in making an excessive fee determination.
In this case, the Plan Administrator determined that $178.50 of the $279.00 total charge is excessive. In an attempt to assess the facts in this dispute, the Trustees requested information from the Plan Administrator relative to the methodology used in arriving at an excessive fee determination and whether this methodology was applied in processing the claim involved in this dispute. Despite repeated contacts, the Plan Administrator has failed to provide the requested information. Therefore, the Trustees have no alternative other than to decide the dispute based on the evidence submitted.
Based on the information contained in the record, the Trustees are unable to conclude that the Plan Administrator has adopted and applied reasonable procedures to arrive at an excessive fee determination. In the absence of any evidence of such procedures, the Trustees conclude that the Employer is responsible for payment of the total charge of $279.00.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
William Miller, Trustee
Donald E. Pierce, Jr., Trustee