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受托人的意见
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在再保险

投诉人:已故雇员的尚存配偶
被申请人:雇主
ROD案例编号:88-677 - 1993年11月18日

董事会:Michael H. Holl和, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.

The Trustees have reviewed the facts 和 circumstances of this dispute concerning the provision of benefits for the surviving spouse of an Employee under the terms 雇主福利计划的成员.

背景事实

The Complainant is the surviving spouse of an Employee who worked in a classified position for the Respondent until February 13, 1991, when he became disabled due to chronic illness 和 was unable to return to work. 皇冠搏彩中心网站记录显示该员工工作时间超过2年,000 hours for the Respondent during the 24-month period immediately prior to his date last worked. 员工收到疾病和意外事故(“S”)&A) 1991年2月21日至1992年3月9日的福利. 被申请人 provided continued health benefits 和 life insurance coverage for the Employee through March 15, 1992. 雇员于1992年4月18日去世，享年50岁.

The Social Security 政府 notified the Complainant by letter dated May 28, 1992 that her husb和 was awarded Social Security 残疾 Insurance (“SSDI”) benefits effective August 1, 1991. 因为该员工被授予SSDI, 未满55岁并已完成20年以上的征召服务, the Respondent reinstated the Employee’s health benefits coverage from March 16, 直到4月18日去世, 1992年根据第二条C款. (1)雇主福利计划. 被申请人, 然而, denied the Complainant’s request for a life insurance benefit 和 health benefits coverage beyond April 31, 1992.

The representative for the Complainant states that the Complainant is entitled to a life insurance benefit 和 健康的延续 benefits coverage beyond April 31, 1992 because the Complainant’s husb和 was being compensated as an active Employee at the time of his death. The representative also states that the Respondent did not notify the Complainant’s husb和 that his life insurance coverage had been terminated or offer him the conversion privilege provided under the Employer Benefit Plan.

答辩人说第二条C. provides life insurance coverage for a disabled Employee only if the Employee is receiving or would be eligible to receive S&一个好处. 答辩人称，申诉人的丈夫有资格获得S&A ceased prior to his death; therefore, 他在死亡时没有资格获得人寿保险. 答辩人认为，根据第二条E款. (3), the Complainant is eligible for health benefits coverage only to the end of the month in which her husb和 died.

争端

Is the Respondent required to provide the Complainant a life insurance benefit 和 health benefits coverage beyond the month in which her husb和 died?

双方立场

Position of the Complainant: 被申请人 is required to provide a life insurance benefit 和 health benefits coverage for the Complainant beyond April 30, 1992 because the Complainant’s husb和 was being compensated as an active Employee at the time of his death. 也, the Respondent failed to notify the Complainant’s husb和 of the conversion privilege under the Employer Benefit Plan.

被访者的职位:残疾员工, the Complainant’s husb和 was not entitled to life insurance coverage at the time of his death; therefore, 投诉人无权获得人寿保险赔偿. The Complainant is only entitled to receive health benefits coverage to the end of the month in which her husb和 died, 1992年4月, 根据第II条E款. (3)雇主福利计划.

相关的规定

雇主福利计划第I(1)、(2)、(4)条规定:

第一条-定义

下列术语具有本协议规定的含义:

(1) “雇主”指(雇主名称).

(2) “工资协议”指1988年全国烟煤工资协议, 如不时修订及任何后续协议.

(4) “雇员”系指为雇主从事保密工作的人员, 有资格获得本协议项下的福利.

第二条丙. (1)、(3)、E. 雇主福利计划第(1)、(2)、(3)条规定:

第二条-资格

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

C. 残疾员工

In addition to disabled Pensioners who are receiving pension benefits 和 are therefore entitled to receive health benefits under paragraph B of this Article II, 第3条规定的健康福利也应提供给下列任何雇员:

(1) (a) 已完成20年的信用服务, including the required number of years of signatory service pursuant to Article IV C (6) of the 1974 Pension Plan or any corresponding paragraph of any successor thereto, 和

(b) 没有达到55岁，并且

(c) became disabled after December 6, 1974 while in classified employment with the Employer, 和

(d) is eligible for Social Security 残疾 Insurance Benefits under Title II of the Social Security Act or its successor;

(3) 是接收还是会接收?, 正确应用后, be eligible to receive Sickness 和 Accident Benefits pursuant to the Wage Agreement.

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

E. 已故雇员或退休人员的尚存配偶及受养人

Health benefits under Article III shall be provided to (i) any unmarried surviving spouse (who was living with or being supported by the Employee or Pensioner immediately prior to the Employee’s or Pensioner’s death) 和 (ii) such spouse’s unmarried surviving dependent children as defined in subparagraphs (2) 和 (5) of paragraph D of an Employee or Pensioner who died:

(1) As a result of a mine accident occurring on or after the effective date of the Plan while the Employee was working in a classified job for the Employer;

(2) Under conditions which qualify such spouse for a Surviving Spouse benefit under the 1974 Pension Plan or any successor thereto;

(3) At a time when such Employee or Pensioner is entitled to receive health benefits pursuant to paragraph A, B, (二)本条第(三)款, provided that (i) if such Employee or Pensioner died prior to the effective date of the Wage Agreement 和 the spouse is not eligible for a Surviving Spouse’s benefit, then only for the period that the spouse is eligible to receive death benefits in installment payments pursuant to paragraph C of Article III, or (ii) if such Employee or Pensioner died on or after the effective date of the Wage Agreement 和 the spouse is not eligible for a Surviving Spouse’s benefit 和 life insurance benefits or death benefits are payable in a lump sum, then only for 60 months following the month of the death of such Employee or only for 22 months following the month of the death of such Pensioner. 如果人寿保险赔偿金不支付, health benefits shall be provided only to the end of the month in which the Employee or Pensioner died.

第三条A. (10)(b)雇主福利计划的相关部分规定:

A. 健康的好处

(10) 一般规定

(b) 政府

The Plan Administrator shall give written notice to each employee of the termination of extended coverage under the Benefit Plan. Such notice shall explain the conversion privileges of the Benefit Plan 和 the enrollment procedures to be followed. Failure to provide such notice shall not extend coverage beyond the period otherwise provided in the Benefit Plan.

第三条B. (1)雇主福利计划相关部分规定:

B. 人寿及意外死亡及伤残保险
(1) 积极的员工

Life 和 accidental death 和 dismemberment insurance will be provided for Employees, 如第二条所述, A和C部分(3)…….

第三条D. 雇主福利计划的(1)(a)、(b)、(d)及(3)(a)项规定:

D. 一般规定

(1) 续保

(a) 裁员

如果雇员因裁员而停止工作, 健康的延续, 人寿、意外死亡和肢解保险的保险范围如下:

工作时数
24 .雇主
连续日历月
紧接前一时期 保险期限
雇员入职日期 继续
最后的工作 最近工作日期

2000小时以上 月加余额
12个月
500或更多，但少于 月加余额
2000小时 6个月
少于500小时 30天

(b) 残疾

第二条另有规定的除外, 部分C, 雇员因残疾而停止工作, 雇员将有资格继续保持健康, life 和 accidental death 和 dismemberment coverage while disabled for the greater of (i) the period of eligibility for Sickness 和 Accident benefits, 或(ii)上述(a)项附表所列期间.

(d) 最大续保范围

在任何情况下，(a)条款的任何组合均不得, (b), (c), (e) or (g) above result in continuation of coverage beyond the balance of the month plus 12个月 from the date last worked.

(3) 转换特权

(a) 人寿保险
Upon application to the insurance carrier within 31 days after life insurance coverage terminates, 雇员可以, 以适用的州保险法为准, 在个人保单下安排继续人寿保险保障, 金额不超过35美元,没有可保证明的. Such individual policy may be on any one of the forms of policy then customarily issued by the insurance company, other than a policy of term insurance or one which provides disability benefits in the event of accidental death, 和 will be issued at the rate applicable to the Employee’s age 和 class of risk at the time.

讨论

第三条D. (1) (b)雇主福利计划规定, 雇员因残疾而停止工作, 雇员将有资格继续保持健康, life 和 accidental death 和 dismemberment insurance while disabled for the greater of (i) the period of eligibility for Sickness 和 Accident benefits or (ii) the period based on the number of hours worked as set forth in 第三条D. (1) (a). 2月13日，雇员因残疾停止工作, 1991, 在2上做功,000 hours for the Respondent during the 24-month period prior to his date last worked, 雇员有资格继续享受健康, life 和 accidental death 和 dismemberment coverage for the balance of the month of February 1991 plus 12个月 (through February 28, 1992), 第二条D款所允许的最长期限. (1) (d).

第三条B. (1)雇主福利计划 provides life 和 accidental death 和 dismemberment insurance coverage to active Employees. The Complainant states that her husb和 was being compensated as an active Employee at the time of his death on April 18, 1992. 然而, the pay stubs submitted by the Complainant indicate that the Employee received compensation for four days of floating holiday on January 5, 1992年，并于3月15日休假十天, 1992. The Complainant’s husb和’s last day of pay for hours worked as an Employee was on February 13, 1991. 相应的, the Complainant’s husb和 was not being compensated as an active Employee at the time of his death on April 18, 1992.

第三条D. (3)(a) 雇主福利计划的成员 provides that if an Employee’s life insurance coverage terminates, 雇员可以 convert to an individual policy upon application to the insurance carrier within 31 days of such termination. 第三条A. (10) (b) provides that the Plan Administrator shall give written notice to an Employee of the termination of extended coverage 和 of the conversion privileges provided under the Employer Benefit Plan. 根据第三条A款. (10)(b), 然而, failure to provide such notice shall not extend coverage beyond the period otherwise provided in the Employer Benefit Plan. The Complainant’s husb和 was not eligible for life insurance coverage under the Employer Benefit Plan at the time of his death because his eligibility for such benefit terminated on February 28, 1992. Although the Complainant contends that the Respondent should be responsible for payment of an insurance benefit, 第三条A. (10) (b) clearly states that failure to provide notice of the termination of coverage shall not extend coverage beyond the period otherwise provided under the Employer Benefit Plan.

第二条E. (1) 和 (2) 雇主福利计划的成员 set forth two alternative circumstances under which a surviving spouse may qualify for health benefits coverage until remarriage. 投诉人无权享有第II条E项下的保险. 因为她丈夫的死不是矿难的结果. 投诉人无权享有第II条E项下的保险. (2)因为, 作为雇员在退休年龄前去世的未亡配偶, she is unable to satisfy the eligibility requirements for a Surviving Spouse benefit under the terms of the 1974 Pension Plan. 第二条E. (3)雇主福利计划规定, 如果人寿保险赔偿金不支付, health benefits coverage for the surviving spouse of an Employee 和 her dependent children shall be provided only to the end of the month in which the Employee died. Inasmuch as life insurance benefits were not payable at the time of the Complainant’s husb和’s death on April 18, 1992, the Respondent is not responsible for providing health benefits coverage for the Complainant 和 her dependents beyond April 30, 1992.
受托人的意见

被申请人 is not required to provide a life insurance benefit to the Complainant. 被申请人 is also not required to provide health benefits coverage for the Complainant beyond April 30, 1992, 符合第II条E款的条款. 雇主福利计划的成员.