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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-301 – November 28, 1983
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean,
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 health benefits coverage for an Employee by the Employer’s Benefit Plan and
hereby render their opinion on the matter.
Background Facts
The Complainant states that he was employed by the Respondent from May 1982 through
August 1982. UMWA Health and Retirement Funds’ records show that the Respondent,
signatory to the National Bituminous Coal Wage Agreement of 1981, reported hours worked for
the Complainant for each month beginning May 1982 through September 1982. The
Complainant’s spouse became pregnant in October 1981. On or about June 9, 1982, the
Complainant’s spouse incurred obstetrical and hospital charges. The Respondent provided health
benefits coverage for the Complainant effective July 1, 1982. The coverage was terminated July
31, 1982, by the insurance carrier due to non-payment of premiums by the Respondent. The
obstetrical and hospital charges incurred by the Complainant’s spouse were not paid by the
Employer’s Benefit Plan. Information submitted by the Complainant includes a letter he
received from the Employer’s insurance carrier indicating that it would not have paid the
spouse’s charges because, under its policy, maternity and obstetrical charges are paid only after
the policy has been in effect for nine (9) consecutive months.
Dispute
Is the Respondent responsible for the provision of health benefits coverage for the Complainant’s
spouse s obstetrical and hospital charges incurred on or about June 9, 1982?
Positions of Parties
Position of Complainant: The Complainant claims that the applicable Employer’s Benefit Plan
imposes liability for the provision of maternity benefits on the employer at the time of the child’s
birth rather than the employer of record at the time of the child’s conception.
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Resolution of Dispute
Case No. 81-301
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Position of Respondent: The Respondent has not replied to our correspondence.
Pertinent Provisions
Article I (I), (2), (4) and (7) of the Employer’s Benefit Plan provide:
Article I – Definitions
The following terms shall have the meanings herein set forth:
1. “Employer” means (coal company)
2. “Wage Agreement” means the National Bituminous Coal Wage Agreement of
1981, 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.
7. “Dependent” shall mean any person described in Section D of Article II hereof.
Article II A (4) and 0 (1) and (2) of the Employer’s Benefit Plan provide:
Article II – Eligibility
The persons eligible to receive the health benefits pursuant to Article III are as follows:
A. Active Employees
(4) A new Employee will be eligible for health benefits from the first day
worked with the Employer.
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 paragraph A, B, or C of this Article III:
1. A spouse who is living with or being supported by an eligible Employee or
Pensioner;
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Resolution of Dispute
Case No. 81-301
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2. Unmarried dependent children of an eligible Employee or Pensioner who have not
attained age 22;
Article III A 3(c) of the Employer’s Benefit Plan provides:
Article III – Benefits
A. Health Benefits
3. Physicians’ Services and Other Primary Care.
(c) Obstetrical Delivery Services
Benefits are provided for a female Beneficiary for obstetrical
delivery services (including pre- and post-natal care) performed by
a physician. Benefits will also be provided if such delivery is
performed by a midwife certified by the American College of
Nurse Midwifery and” licensed where such licensure is required.
Such benefits will also be provided for termination of pregnancy
but only if medically necessary and is so certified to and such
services are performed by a licensed gynecologist or a surgeon.
Discussion
The Respondent has not answered correspondence from the Trustees. This opinion is therefore
based on information submitted by the Complainant as well as other information available to the
Trustees.
Under Article II of the Employer Benefit Plans, an Employee and his eligible dependents,
including his spouse, are eligible for benefits coverage from the Employee’s first day worked
throughout his entire period of employment with a signatory Employer. The Complainant has
stated that he was employed by the Respondent from May through August 1982. UMWA Health
and Retirement Funds’ records indicate that the Respondent reported work hours for the
Complainant for the period May through September 1982. Therefore, the Complainant’s spouse
was eligible for benefits coverage at the time she received obstetrical and hospital services
related to the delivery of her child.
The only remaining question is whether the services are a covered benefit under the terms of the
Employer Benefit Plans. Under Article III.A. (3) (c) of the Employer Bene!it Plans, benefits are
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Resolution of Dispute
Case No. 81-301
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provided for obstetrical delivery services, including pre- and post-natal care, if performed by a
physician or a certified and licensed midwife. Therefore, the obstetrical and hospital charges
incurred by the Complainant’s spouse are a covered benefit which the Respondent is required to
provide under his Employer’s Benefit Plan.
Information submitted by the Complainant includes a statement by the Respondent’s insurance
carrier that the policy purchased by the Respondent would not have provided benefits for the
spouse’s maternity and obstetrical services, because the policy was not in effect for nine
consecutive months when the services were received. The fact that the terms of a policy
purchased by an Employer may differ from the terms of the Employer Benefit Plan, which the
Employer is required to maintain pursuant to Article II (c) (3) (i) of the 1981 Wage Agreement,
would not relieve the Employer of his obligation to provide benefits in accordance with the
terms of the Employer Benefit Plans.
Opinion of Trustees
The Trustees are of the opinion that the Respondent is responsible for the provision of maternity
benefits for the Complainant’s spouse.