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OPINION OF TRUSTEES
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In Re

Complainant: Employees
Respondent: Employer
ROD Case No: 02-022 – April 19, 2006

Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.

受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.

Background Facts

投诉人包括现时受雇于被投诉人的雇员，以及受雇于被投诉人期间曾缴付医药费的前雇员. 申诉人代表声称，答辩人没有按照《皇冠搏彩中心》和雇主福利计划的规定及时支付健康索赔. As a result, 投诉人已收到供应商发出的催收通知和声明，威胁若未付账单未付将采取催收行动.

On March 11, 2005, a Funds’ staff member spoke with the Respondent’s Plan Administrator
who stated that Acordia was the Respondent’s insurance carrier until April 1, 2004, when the Respondent then changed to Corporate Benefit from April 1, 2004 to September 30, 2004. Allied Benefits Administration has been the insurance carrier since October 1, 2004. In February 2005, the Plan Administrator stated that he received a large envelope of claims from Corporate Benefit. Some of the claims had been paid and others were duplicates. He stated that he informed employees that if they had unpaid claims for services prior to October 2004, they should send him a copy of the bills.

被投诉人的一名代表提交的资料表明，最初在纠纷中提交的许多医疗账单已经支付. For example, according to the Respondent’s representative, a bill submitted by one of the Complainants for an emergency room service dated March 27, 2004 was paid by the Respondent on July 14, 2005. Another example is a request for reimbursement for prescription drugs purchased in March 2003 and April 2004. The Respondent reimbursed the Complainant on February 22, 2005.

After the ROD was filed, 投诉人代表与计划管理人合作，对未支付的索赔进行分类，试图解决争端. According to the Complainants’ representative, although the Respondent paid a number of outstanding claims originally submitted, late payment of claims by the Respondent continues to be an on-going problem for the Employees. Therefore, the representative requested that the dispute be presented to the Trustees for review.

The Respondent is signatory to a modified 2002 National Bituminous Coal Wage Agreement (“2002 Wage Agreement”), effective January 1, 2003 through December 31, 2006. 本协议根据80/20计划提供健康保险，并要求员工支付每月从员工工资总额中扣除的保费.

Dispute

被投诉人是否按照《官方网站》和《皇冠搏彩中心》的规定为申诉人提供健康福利?

Positions of the Parties

投诉人的立场:被投诉人没有按照《官方网站》和雇主福利计划的规定提供医疗保险，因为投诉人收到了供应商发出的催收通知和声明，威胁说如果未付账单不付，将采取催收行动.

答辩人的立场:答辩人根据《官方网站》的规定，为申诉人提供医疗保险.
Many of the medical bills originally submitted in the dispute have been paid. Furthermore, 申诉人代表提交的资料"是有选择性的，显然企图将公司描绘成没有就医疗账单困境付款或取得进展.”

Pertinent Provisions

Article XX (c)(3)(i) of the National Bituminous Coal Wage Agreement of 2002 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), 本协议所涵盖的雇员的健康和其他非养恤金福利，以及1974年养恤金计划和信托下的养恤金领取者，其最后签署人的分类就业是在该雇主. 雇主根据该等计划向其合格参与人提供的福利应在本协议有效期内由该雇主按该等计划规定的水平予以保证.

Article I (1), (2) and (4) of the 2002 Employer Benefit Plan provide:

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 2002, 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. (5) of the 2002 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

(5) A new Employee will be eligible for health benefits from the first day worked with the Employer.

Discussion

《皇冠搏彩中心》第XX (c)(3)(i)条要求雇主提供雇主福利计划，该计划通过保险公司实施，提供健康福利和其他非养老金福利. 它还要求“在本协议有效期内，雇主根据该等计划向其合格参与人提供的福利应按该等计划规定的水平予以保证。.” Article II. 2002年《皇冠搏彩中心》A款规定，为签约雇主从事分类工作的在职雇员提供健康福利.

在本案中，投诉人因被投诉人未能及时支付投诉人的医药费而收到催收通知. Although the Employer Benefit Plan does not specify a time period for processing and payment of medical claims, 劳工部规定要求在30天内支付干净索赔-不需要额外信息处理的索赔. The Funds, for example, reviews seventy percent of claims within a four-day period and pays a reviewed claim within seven to ten days. Ninety percent of claims are reviewed within a ten-day period.

In ROD 98-046, 受托人处理了及时处理无争议或干净的索赔要求的问题，并发现雇主或其代理人处理和支付健康福利索赔要求所花费的时间不应导致对受益人采取托收行动，也不应导致任何其他损害受益人信誉的行动. 受托人还指出，雇主必须隔离并保护受益人免受提供商发起的任何此类诉讼的影响。.

被投诉人声称，它正在“解决医疗账单难题”，并已支付了许多最初的索赔. However, 根据申诉人提交的关于其已支付的索赔的资料- 3月27日的医疗索赔, 2004 was paid on July 14, 2005—the Respondent’s progress is insufficient.

Opinion of the Trustees

被投诉人未能及时处理申诉人提出的明确或无可争议的健康福利要求，不符合《官方网站》或《皇冠搏彩中心》的要求. 被投诉人或其代理人为裁决无争议的健康福利索赔所花费的处理时间不得导致对投诉人采取催收行动，也不得导致损害投诉人信誉的任何其他行动. The Respondent must insulate and defend Complainants against any such actions initiated by the provider(s).