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OPINION OF TRUSTEES
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In Re

Complainant: Disabled Employee
Respondent: Employer
ROD Case No: 84-610 – April 20, 1988

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 provision of benefits coverage for a disabled Employee under the terms of the Employer Benefit Plan.

Background Facts

The Complainant performed classified work for the Respondent from November 1980 until November 25, 1986, when he became disabled as a result of a job-related injury. According to Funds’ records, the Complainant worked over 2,000 hours for the Respondent during the 24-month period immediately prior to his date last worked.

Information received by the Funds indicates that the Respondent terminated the Complainant’s health benefits coverage on July 1, 1987. The Complainant contends that he is entitled to continued benefits coverage through November 30, 1987, and that the Respondent is responsible for payment of his outstanding medical bills incurred between July 1, 1987 and November 30, 1987.

Dispute

Whether the Respondent is responsible for payment of the outstanding medical bills incurred by the Complainant and his eligible dependents between July 1, 1987 and November 30, 1987.

Position of the Parties

Position of the Complainant: The Respondent is responsible for payment of the Complainant’s outstanding medical bills incurred between July 1, 1987 and November 30, 1987.

Position of the Respondent: The Respondent has not responded to repeated correspondence from Funds’ staff regarding its position in this dispute.

Pertinent Provisions

Article I (1), (2) and (4) of the Employer Benefit Plan provides:

Article I – Definitions

The following terms shall have the meanings herein set forth:

(1) “Employer” means (“Employer’s Name”).

(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 C. (3) of the Employer Benefit Plan provides:

Article II – Eligibility

The persons eligible to receive the health benefits pursuant to Article III are as follows:

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 also 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.

Life and accidental death and dismemberment insurance shall also be provided to Employees described in (3) above.

Article III D. (1)(a), (b) and (d) of the Employer Benefit Plan provide:

Article III – Benefits

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:

Number of Hours Worked for the
Employer in the 24 Consecutive
Calendar Month Period Immediately
Prior to the Employee’s Date Last Period of Coverage Continuation
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 2,000 2,000 hours

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.

(d) Maximum Continuation of Coverage

In no event shall any combination of the provisions of (a), (b), (c), (e) or (g) above result in continuation of coverage beyond the balance of the month plus 12 months from the date last worked.

Discussion

Article II C. (3) of the Employer Benefit Plan provides health benefits coverage for a disabled Employee who is receiving or would be eligible to receive Sickness and Accident Benefits pursuant to the Wage Agreement. In addition, Article III D. (1)(b) provides continued benefits coverage for an Employee who ceases work because of disability for the greater of (i) the period of eligibility for Sickness and Accident benefits, or (ii) the period based on the number of hours worked as set forth in Article III D. (1)(a). Inasmuch as the Complainant worked over 2,000 hours for the Respondent during the 24-month period prior to his date last worked, November 25, 1986, the Respondent is responsible for providing continued health benefits coverage for the Complainant through November 30, 1987, the maximum period allowable under Article III. D. Accordingly, the Respondent is responsible for payment of the covered medical expenses incurred by the Complainant and his eligible dependents between July 1, 1987 and November 30, 1987.

Opinion of the Trustees

The Respondent is responsible for payment of the covered medical expenses incurred by the Complainant and his eligible dependents between July 1, 1987 and November 30, 1987, under the terms of the Employer Benefit Plan.