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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 84-050 - 1985年10月29日
董事会:Joseph Connors, Sr., Chairman; Paul R. 院长，受托人. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.
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 health benefits coverage under the terms of the 雇主 Benefit Plan.
背景事实
被申请人 has denied benefits for the Complainant’s son stating that he does not satisfy the eligibility requirements as set forth in 第二条D. (5)雇主福利计划 and is not disabled within the meaning of Question and Answer H-6 (81) (enclosed herein).
申诉人声称，他的儿子, 谁是2月25日出生的, 1963, 从16岁起就残疾了.” The Complainant has asked that the Respondent provide his son with health benefits coverage as a disabled adult dependent.
争端
Is the Respondent responsible for the provision of health benefits coverage for the Complainant’s son as a disabled adult dependent?
各方立场
Position of the 原告: 被申请人 is responsible for providing health benefits coverage for his disabled son.
Position of the 被申请人: The Complainant’s son is not disabled within the meaning of Question and Answer H-6 (81) and is not, 因此, an eligible adult dependent as defined by Article 11 D. (5)雇主福利计划. 相应的, the Respondent is not responsible for the provision of health benefits coverage for the Complainant’s son.
相关的规定
第二条D. (5)雇主福利计划 provides:
第二条-资格
D. 合格的家属
Health benefits under Article III shall be provided to the following members of the family of any 员工, 养老金领取者, or disabled 员工 receiving health benefits pursuant to paragraphs A, B, 或本条第2款(C)项:
(5) 受抚养儿童(任何年龄), 合资格雇员的, 领取养老金者或配偶, who are 精神ly retarded or who become disabled 在22岁之前 and such disability is continuous and are either living in the same household with such 员工 or 养老金领取者 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.
问题与回答(Q&A) H-6(81)(第1部分)规定:
主题: HEALTH BENEFITS; Disabled Children H-6 (81)
Reference: (50B) II C(5), II D; (74B) II C(5), II D
问题:
Certain dependent children (of any age) are eligible for health benefits if they are 精神ly retarded or become disabled 在22岁之前 and such disability is continuous.
(1) What is the standard for determining whether the dependent child is “精神ly retarded or disabled”?
答:
(1) A person is “精神ly retarded or disabled” if the person has any professionally determinable physical, 精神, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.
讨论
第二条D. (5)雇主福利计划 stipulates that health benefits coverage will be provided to dependent children of any age who are 精神ly retarded or who become disabled 在22岁之前, 残疾是持续的. Q&A H-6 (81), provides that “a person is “精神ly retarded or disabled’ if the person has any professionally determinable physical, 精神, or psychological impairment which precludes the person’s living or functioning independently of his/her parent(s) or an institution.”
申诉人声称，他的儿子 从16岁起就残疾了” and is 因此 eligible for health benefits coverage as a disabled adult dependent. 被申请人, 然而, denies responsibility for the provision of health benefits coverage stating that the Complainant’s son is not disabled within the meaning of 第二条D. (5)雇主福利计划 and of Q&A H-6 (81).
In response to this request for Resolution of 争端, a Funds medical consultant reviewed the evidence submitted and has requested and obtained medical records from the attending physician in an effort to determine whether, 在22岁之前, the Complainant’s son was disabled as defined by the provisions of Q&A H-6 (81). Based on the medical evidence submitted, it cannot be determined that the son has a physical, 精神 or psychological impairment which precludes his living or functioning independent of his parents or an institution. Therefore, in accordance with the provisions of 第二条D. (5)雇主福利计划, as qualified by Question and Answer H-6-(81), the Complainant’s son is not eligible to receive health benefits coverage as a disabled adult dependent.
受托人的意见
被申请人 is not responsible for the provision of health benefits coverage for the Complainant’s son.