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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-162 – August 14, 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
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 July 1982 until
January 1983, when he was laid off. On August 28, 1985, the Complainant was recalled to work
for the Respondent in a classified position. The Complainant has stated that after he was
recalled, the Respondent did not provide any health benefits coverage for him until November
1988, and furthermore, that the Benefit Plan implemented by the Respondent at that time did 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 (“Wage
Agreement”) of 1984.
The Complainant has submitted a copy of a bill for vision care services rendered on January 4,
1986, and copies of receipts indicating he paid the bill in full. The Complainant has also
submitted receipts for prescription charges incurred between September 24, 1985 and March 26,
1986, also paid in full. The Complainant has stated that all of these claims were submitted to the
Respondent, but to date he has received no payment nor any Explanation of Benefits.
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
Opinion of Trustees
Resolution of Dispute
Case No. 84-162
Page 2
Is the Respondent responsible for the provision of health benefits coverage for the Complainant
and his eligible dependents at the level prescribed by the terns of the Employer Benefit Plan?
Positions 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:
(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. (3) of the Employer Benefit Plan provides in pertinent part:
Opinion of Trustees
Resolution of Dispute
Case No. 84-162
Page 3
Article II – Eligibility
The persons eligible to receive the health benefits pursuant to Article III are as follows:
A. Active Employees
(3) …any Employee of the Employer who is not actively at work* for the
Employer on the effective date of the Wage Agreement will not be eligible
for coverage under the Plan until he returns to active employment with the
Employer.
Article III A. 4 (a), (8) and (9) of the Employer Benefit Plan provides in pertinent part:
Article III – Benefits
A. Health Benefits
(4) Prescription Drugs
(a) Benefits Provided
Benefits are provided for insulin and prescription drugs (only those
drugs which by Federal or State law require a prescription)
dispensed by a licensed pharmacist and prescribed by a (i)
physician for treatment or control of an illness or a
nonoccupational accident or (ii) licensed dentist for treatment
following the performance of those oral surgical services set forth
in (3)(e).
(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. Copayments for covered Health Benefits are established as follows:
Benefit Co-Payment
(a) Physician services as an out- Working Group —
$7.80
patient as set forth in Section A per visit up to a maxi-
(2) and physician visits in con- mum of $180 per 12-
nection with the benefits set month period (**) per
Opinion of Trustees
Resolution of Dispute
Case No. 84-162
Page 4
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(J) paragraph (f).
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*
Actively at work includes an Employee of the Employer who was actively at work on
September 30, 1984, and who returns to active work with the Employer two weeks after the
effective date of the Wage Agreement,
**The 12-month periods shall begin on the following dates: March 27, 1984; March 27, 1988;
March 27, 1986 and March 27, 1987.
Benefit Co-Payment
(5) Prescription drugs and insulin, $8 per prescription or
as set forth in Section A(4) and refill up to a $80
take-home drugs following a hos- maximum per 12-month
pital confinement as set forth in period(*
) per family.
Section A(1)(a). Note: For purposes of
this co-payment proIf 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.
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*The 12-month periods shall begin on the following dates: March 27, 1984; March 27, 1985;
March 27, 1986 and March 27, 1987.
Opinion of Trustees
Resolution of Dispute
Case No. 84-162
Page 5
(9) Vision Care Program
Actual Charge Up To
(a) Benefits Maximum Amount Frequency Limits
Vision Examination $20 Once every 24 months
Per Lens (Maximum = 2) Once every 24 months
– Single Vision 10
– Bifocal 15
– Trifocal 20
– Lenticular 25
– Contact 18
Frames 14 Once every 24 months
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 returned to active employment in a
classified position for the Respondent on August 28, 1988, he was eligible for health benefits
coverage as an active employee from that date 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. Article III A. (9) of the
Plan specifies the benefits provided to beneficiaries for vision care services. Levels of benefits to
be provided to Employees and their dependents are established through collective bargaining and
may not be unilaterally changed by an Employer. The Respondent’s failure to provide coverage
for prescription drugs and vision care services is inconsistent with the provisions of the 1984
Wage Agreement and the Employer Benefit Plan.
Opinion of the Trustees
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.
