_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-205 – December 3, 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 claims that he was employed by the Respondent, a signatory company, in a classified position from June 19, 1985 through May 2, 1986. The Complainant has stated that the Benefit Plan implemented by the Respondent does 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 medical bills for services rendered to him and to his wife between November 22, 1985 and April 29, 1986. During this period, the Respondent provided health benefits coverage for the Complainant through Blue Cross/Blue Shield. Under the Blue Cross/Blue Shield policy, the Complainant was required to pay $300 toward the cost of medical services for each of the first three policy beneficiaries. Blue Cross/Blue Shield was to pay up to 80% of the remaining cost of service.
The Complainant asks whether the Respondent is 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 for the provision of health benefits coverage for the Complainant as an Employee and for 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 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 classified employment was with such Employer. The benefits provided pursuant to such plans shall be guaranteed during the term of this Agreement by each 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) of the Employer Benefit Plan provides:
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..:
(4) A new Employee will be eligible for health benefits from the first day worked with the Employer.
Article III A (8) and D. (1)(a) and (b) of the Employer Benefit Plan provide:
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 $180 per 12-
nection with the benefits set forth month period(*) per
in Section A(3), paragraph (c) but family.
only for pre- and post-natal visits Non-Working Group —
if the physician charges separately $5 per visit up to a
for such visits in addition to the maximum of $100 per
– charge for delivery, and paragraphs 12-month period(*)
(g) through (m), paragraph (n) per family.
except inpatient surgery, paragraph
(o) and Section A(7) paragraph
(b) Prescription drugs and insulin, $5 per prescription or
as set forth in Section A(4) and refill up to a $80
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 provi-
If an employee is covered under an sion, a prescription or
employee Plan (established pursuant refill shall be deemed
to the NBCWA of 1978) by more than to be each 30 days (or
one signatory employer during a fraction thereof)
12-month period (*), the total supply.
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.
Discussion
Article XX Section (c)(3)(i) of the 1984 Wage Agreement requires a signatory employer to establish and maintain an Employer Benefit Plan to provide health and other non-pension benefits for its Employees. The Wage Agreement stipulates that benefits provided by the Employer pursuant to such plans 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 June 19, 1988 until May 2, 1986, he is eligible for health benefits coverage during this period of employment.
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 with a deductible benefit payment is inconsistent with the provisions of the 1984 Wage Agreement and the Employer Benefit Plan. Accordingly, the Respondent is responsible for payment of benefits in conformity with the provisions of the 1984 Wage Agreement.
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. Accordingly, the Respondent is responsible for payment of benefits in conformity with the provisions of the 1984 Wage Agreement.