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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-410 – January 23, 1997
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson, and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant is employed by the Respondent in a classified position. The Complainant’s daughter, who was born on October 2, 1965, was covered as a dependent under the Respondent’s Benefit Plan until she attained age 22 and her coverage was terminated.
The representative for the Complainant contends that the Complainant’s daughter is entitled to health benefits coverage beyond age 22 because she became disabled prior to attaining age 22 and her disability is continuous. The Complainant’s daughter has never lived independently of her parents. A report from the Social Security Administration office indicates that the Complainant’s daughter has been receiving Supplemental Security Income (SSI) benefits based on a disability onset date of January 1985.
At the Respondent’s request, the Complainant’s daughter was examined for five days as an inpatient at a local hospital to determine if she was disabled. The consultant for the Respondent determined that she was disabled and that she could attend a vocational training center to become independent. The consultant also recommended that the daughter: 1) attend outpatient psychiatric counseling; 2) take antidepressant and/or antianxiety medication; 3) live in a group home while attending vocational training. The Complainant’s daughter has not attended a vocational training center and the Respondent has refused to provide health benefits coverage for the daughter.
This ROD was originally submitted to the Trustees in April 1991 but was withdrawn prior to a decision being issued because the Complainant and the Respondent agreed to settle the dispute. The Complainant requested the ROD be re-opened due to the Complainant’s dissatisfaction with the settlement.
Dispute
Is the Respondent required to provide health benefits coverage for the Complainant’s daughter as a disabled adult dependent?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide health benefits coverage for the Complainant’s daughter as a disabled dependent because she became disabled prior to attaining age 22 and remains so disabled.
Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s daughter until she attends a vocational training center.
Pertinent Provisions
Article II D. (5) of the Employer Benefit Plan provides:
Article II – Eligibility
The persons eligible to receive the health benefits pursuant to Article III are as follows:
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:
(5) Dependent children (of any age), of an eligible Employee, Pensioner or spouse, who are mentally retarded or who become disabled prior to attaining age 22 and such disability is continuous and are either living in the same household with such Employee or Pensioner or are confined to an institution for care or treatment. Health benefits for such children will continue as long as a surviving parent is eligible for health benefits.
Discussion
Article II D. (5) of the Employer Benefit Plan states that health benefits coverage shall be provided to dependent children of any age who became disabled prior to attaining age 22 and whose disability is continuous. Q&A H-6 (81) provides that a person is “disabled” if the
person has “any professionally determinable physical, mental, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.”
The Respondent has determined that the Complainant’s daughter meets the eligibility requirements under Article II D. (5), but has refused to provide health benefits coverage for the daughter unless she attends a vocational training center. Article II D. (5) of the Employer Benefit Plan states that “[h]ealth benefits for such children will continue as long as a surviving parent is eligible for health benefits.” Thus, the Employer Benefit Plan expressly addresses the conditions under which a dependent child’s eligibility for health benefits terminates. Inasmuch as the Complainant’s daughter meets the eligibility requirements under Article II D. (5) and a surviving parent is eligible for health benefits coverage, the Respondent’s refusal to provide the daughter health benefits coverage unless she attends a vocational training center is contrary to the termination provision of Article II D. (5). and penalizes the Complainant in a manner not authorized by the Plan.
Opinion of the Trustees
The Respondent is required to provide health benefits coverage for the Complainant’s daughter as a disabled adult dependent subject to the requirements of Article II D. (5) of the Employer Benefit Plan.