OPINION OF TRUSTEES
ROD Case No: 84-160 – July 28, 1986
Board of Trustees: Joseph P. 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 responsibility for the provision of health benefits coverage for an Employee by an Employer under the terms of the Employer Benefit Plan.
The Complainant worked in a classified position for the Respondent from June 26, 1984, until he was laid off on September 28, 1984. Funds’ records show that a total of 580 hours worked were reported for the Complainant by the Respondent during this period.
at the time of layoff, the Respondent initially determined that the Complainant had worked less than 500 hours and was thereby entitled to 30 days of continued health benefits coverage, through October 28, 1984. Several months later, at the Complainant’s request, the Respondent recalculated the number of hours worked and found that the Complainant was actually entitled to continued health benefits coverage for the balance of the month of September 1984 plus six months (through March 31, 1985). The Respondent thereupon agreed to pay, upon submission of proof, the Complainant’s covered medical bills incurred during the period of liability. Despite such an agreement, the Complainant has submitted evidence indicating that the Respondent has failed to pay claims totaling $460.58 for medical services rendered between October 11, 1984 and October 29, 1984.
The Complainant further states that when his health benefits coverage was canceled, his wife’s treatment for infertility was interrupted because the couple could not afford to continue it without insurance. The Complainant asks whether the Respondent is now responsible for coverage of his wife’s remaining infertility treatments since such treatment was begun but not completed prior to March 31, 1985.
Is the Respondent responsible for the provision of continued health benefits coverage for the Complainant and his eligible dependents from September 28, 1984 through March 31, 1985? Is the Respondent responsible for coverage of infertility treatments for the Complainant’s spouse after March 31, 1985, since such treatments were begun but not completed by this date?
Positions of the Parties
Position of the Complainant: The Respondent is responsible for the continuation of the Complainant’s health benefits coverage from September 28, 1984 through March 31, 1985. The Complainant asks whether the Respondent is also responsible for coverage of his wife’s infertility treatments after March 31, 1985, since such treatments were begun but not completed by this date.
Position of the Respondent: The Respondent is responsible for the continuation of the Complainant’s health benefits coverage from September 28, 1984 through March 31, 1985. However, the Respondent is not responsible for coverage of medical services rendered after March 31, 1985, the date that the Complainant ceased to be eligible for continued health benefits coverage under the terms of the Employer Benefit Plan.
Article I. (1), (2), (4) and (7) of the 1981  Employer Benefit Plan provide:
Article I – Definitions
The following terms shall have the meanings herein set forth:
(1) “Employer” means (name of Coal company).
(2) “Wage Agreement” means the National Bituminous Coal Wage Agreement of 1981 , 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.
(7) “Dependent” shall mean any person described in Section D of Article III hereof.
Article II. A. (2) and D. (1) of the 1984 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 III shall be provided to any Employee who:
(2) is on layoff or disabled from the Employer and had continuing eligibility as of the effective date of the Wage Agreement for coverage under the 1981 Employer’s Benefit Plan (“prior Plan”) as a laid off or disabled employee. Coverage for such laid off or disabled Employees shall not continue beyond the date when they would no longer have been eligible for such coverage under the provisions of the prior Plan.
D. Eligible Dependents
Health benefits under Article III shall be provided to the following members of the family of any Employee, Pensioner, or disabled Employee receiving health benefits pursuant to paragraphs A, B, or C of this Article II:
(1) A spouse who is living with or being supported by an eligible Employee or Pensioner;
Article III. A. (11) (a) 2 (ii) and D (1) (a) of the 1984 Employer Benefit Plan provide:
Article III – Benefits
A. Health Benefits
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
2. Services rendered
(ii) subsequent to the period after which a Beneficiary is no longer eligible for benefits under the Plan;
D. General Provisions
(1) Continuation of Coverage
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 Immediately
Prior to the Employee’s Date Period of Coverage Continuation
Last Worked from the Date Last Worked
2,000 or more hours Balance of month plus 12 months
500 or more but less than Balance of month plus 6 months
Less than 500 hours 30 days
Under Article III. D. of the Employer Benefit Plan, the Employer is required to provide continued health benefits coverage to a laid-off Employee for a period determined by the number of hours the Employee worked for the Employer during the 24-month period prior to the Employee’s date last worked. Funds’ records show that the Complainant worked 580 hours for the Respondent during the 24 consecutive calendar months prior to his layoff on September 28, 1984. Accordingly, the Respondent is responsible for the continuation of health benefits coverage for the Complainant and his eligible dependents through March 31, 1985.
Article III. A. (11) of the Employer Benefit Plan specifies that coverage shall not be provided for services rendered subsequent to the termination of the Employee’s period of eligibility for benefits under the Plan. Consequently, the Respondent is not responsible to provide coverage for services rendered after March 31, 1985.
Opinion of the Trustees
The Respondent is responsible for the provision of health benefits coverage for the Complainant and his eligible dependents through March 31, 1985. The Respondent is not responsible to provide coverage for any services rendered after said date.