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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-148 – July 28, 1986
Board of Trustees: Joseph B. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
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 level of health benefits coverage for an Employee under the terms of the Employer Benefit Plan.
Background Facts
The Complainant worked for the Respondent in a classified position from November 13, 1984 until May 10, 1985, when he was injured in a mine accident. A Representative of the Complainant has stated that the Complainant is receiving Workmen’s Compensation for this injury and that he was unable to return to work before December 1, 1985, when the Respondent closed the mine and laid off the Complainant.
The Complainant has stated that the Benefit Plans implemented by the Respondent do not provide health benefits coverage at the level prescribed by the terms of the Employer Benefit Plan established pursuant to the National Bituminous Coal Wage Agreement of 1984. The Complainant has submitted notices from a collection agency of unpaid bills for medical services rendered between January 27, 1985 and May 25, 1985. During this period, the Complainant’s health benefits coverage was implemented through the Guardian Life Insurance Company of America. The Complainant has also submitted receipts for prescription charges he paid in full between October 3, 1985 and November 2, 1985, after his coverage had been transferred to Blue Cross and Blue Shield of Virginia. The Complainant has submitted a copy of his Blue Cross/Blue Shield identification card which indicates that benefit payments are subject to a $100 deductible and, thereafter, are paid up to 80% of the cost of the service. The Complainant believes that this use of an 80/20 health coverage plan is in violation of the 1984 Wage Agreement which seas forth specific co-payments for rendered medical services ($7.50) and for prescriptions ($5.00).
The Complainant asks that the Respondent be found responsible for the provision of health benefits coverage at the level prescribed by the terms of the Employer Benefit Plan. The Respondent has failed to respond to repeated correspondence from the Funds regarding its position in this dispute.
Dispute
Is the Respondent responsible for the provision of health benefits coverage for the Complainant and his eligible dependents at the level prescribed by the Employer Benefit Plan?
Position of the Parties
Position of the Complainant: The Respondent is responsible during the Complainant’s period of eligibility for the provision of health benefits coverage for the Complainant and his eligible dependents at the level prescribed by the Employer Benefit Plan.
Position of the Respondent: The Respondent has failed to present its position in this dispute.
Pertinent Provisions
Article XX Section (c)(3)(i) of the National Bituminous Coal Wage Agreement of 1984 provides in pertinent part:
(c) 1974 Plans and Trusts
(3)(i) Each signatory Employer shall establish and maintain an Employee benefit plan to provide, implemented through an insurance carrier(s), health and other non-pension benefits for its Employees covered by this Agreement as well as pensioners, under the 1974 Pension Plan and Trust, whose last signatory classified employment was with such Employer. The benefits provided by the Employer to its eligible Participants pursuant to such plans shall be guaranteed during the term of this Agreement by that Employer at levels set forth in such plans.
Article I (1), (2), and (4) of the Employer Benefit Plan provide:
Article I – Definitions
The following terms shall have the meanings herein set forth:
1. “Employer” means (coal company).
2. “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1984, as amended from time to time and any successor agreement.
4. “Employee” shall mean a person working in a classified job for the Employer, eligible to receive benefits hereunder.
Article II A. (4) and C. (3) of the Employer Benefit Plan provide:
Article II – Eligibility
The persons eligible to receive the health benefits pursuant to Article III are as follows:
A. Active Employees
Benefits under Article Ill shall be provided to any Employee who:
(4) A new Employee will be eligible for health benefits from the first day worked with the Employer.
C. Disabled Employees
In addition to disabled Pensioners who are receiving pension benefits and are therefore entitled to receive health benefits under paragraph B of this Article II, health benefits under Article III shall be provided to any Employee who:
(3) Is receiving or would, upon proper application, be eligible to receive Sickness and Accident Benefits pursuant to the Wage Agreement.
Article III A. (8) and D. (1)(a) and (b) of the Employer Benefit Plan provides:
Article III – Benefits
A. Health Benefits
(8) Co-Payments
Certain benefits provided in this Plan shall be subject to the co-payments set forth below and such co-payments shall be the responsibility of the beneficiary. The Plan Administrator shall implement such procedures as deemed appropriate to achieve the intent of these co-payments.
* * *
Co-payments for Health Benefits are established as follows:
Benefit Co-Payment
(a) Physician services as an out- Working Group — $7.50
patient as set forth in Section A per visit up to a maxi-
(2) and physician visits in con- mum of $150 per 12-
nection with the benefits set month period(*) per
forth in Section A(3), paragraph family.
(c) but only for pre- and post- Non-Working Group —
natal visits if the physician $5 per visit up to a
charges separately for such visits maximum of $100 per
in addition to the charge for 12-month period(*) per
delivery, and paragraphs (g) family.
through (m), paragraph (n) except
inpatient surgery, paragraph (o)
and Section A(7) paragraph (f).
(b) Prescription drugs and insulin, $5 per prescription or
as set forth in Section A(4) and refill up to a $50
take-home drugs following a hospi- maximum per 12-month
tal confinement as set forth in period(*) per family.
Section A(1)(a). Note: For purposes of this co-payment pro-
If an employee is covered under vision, a prescription
an employee Plan (established or refill shall be
pursuant to the NBCWA of 1978) deemed to be each 30
by more than one signatory days (or fraction
employer during a 12-month thereof) supply. period(*), the total co-payments
made by the employee during
such period shall be counted
toward the 12-month(*) maximum.
*The 12-month periods shall begin on the following dates: March 27, 1984; March 27, 1985; March 27, 1986 and March 27, 1987.
D. General Provisions
(1) Continuation of Coverage
(a) Layoff
If an Employee ceases work because of layoff, continuation of health, life and accidental death and dismemberment insurance coverage is as follows:
Numbers of Hours Worked
for the Employer in the 24
Consecutive Calendar Month Period of Coverage
Period Immediately Prior to Continuation from the
the Employee’s Date Last Worked Date Last Worked
2,000 or more hours Balance of month plus
12 months
_______________________________ ________________________
500 or more but less than Balance of month plus
2,000 hours 6 months
_______________________________ __________________________
Less than 500 hours 30 days
_______________________________ ___________________________
(b) Disability
Except as otherwise provided in Article II, section C, if an Employee ceases work because of disability, the Employee will be eligible to continue health, life and accidental death and dismemberment coverage while disabled for the greater of (i) the period of eligibility for Sickness and Accident benefits, or (ii) the period as set forth in the schedule in (a) above.
Discussion
Article XX Section (c)(3)(i) of the 1984 Wage Agreement requires each signatory Employer to establish and maintain an employer benefit plan to provide health and other non-pension benefits to its employees. The Wage Agreement stipulates that benefits provided by the Employer pursuant to such plan shall be guaranteed during the term of the Agreement by that Employer at levels set forth in such plans. Inasmuch as the Complainant worked in a classified position for the Respondent from November 13, 1984 until May 10, 1985 when he was injured in a mine accident, he was eligible for health benefits coverage as an active employee and continued health benefits coverage as a disabled employee for the period of eligibility as determined under the terms of the Employer Benefit Plan.
Article III, A (8) of the Employer Benefit Plan specifies the co-payments which are the responsibility of the beneficiary for medical services and prescriptions. Levels of benefits to be provided to Employees, Pensioners and their dependents and survivors are established through collective bargaining and may not be unilaterally changed by an Employer. The Respondent’s use of a non-conforming 80/20 health coverage plan and its failure to provide coverage for prescription drugs is inconsistent with the provisions of the 1984 Wage Agreement and the Employer Benefit Plan.
Opinion of the Trustees
The Respondent’s use of a substandard health coverage plan is inconsistent with the express provisions of the 1984 Wage Agreement. The Respondent is responsible for the provision of health benefits coverage for the Complainant and his eligible dependents at the level specified in the Employer Benefit Plan during the Complainant’s period of eligibility as determined under the terms of the Employer Benefit Plan.