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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-050 – October 29, 1985
Board of Trustees: Joseph Connors, Sr., Chairman; Paul R. Dean, Trustee;, William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 under the terms of the Employer Benefit Plan.
Background Facts
The Respondent has denied benefits for the Complainant’s son stating that he does not satisfy the eligibility requirements as set forth in Article II D. (5) of the Employer Benefit Plan and is not disabled within the meaning of Question and Answer H-6 (81) (enclosed herein).
The Complainant contends that his son, who was born on February 25, 1963, “has been disabled since age 16.” The Complainant has asked that the Respondent provide his son with health benefits coverage as a disabled adult dependent.
Dispute
Is the Respondent responsible for the provision of health benefits coverage for the Complainant’s son as a disabled adult dependent?
Position of Parties
Position of the Complainant: The Respondent is responsible for providing health benefits coverage for his disabled son.
Position of the Respondent: The Complainant’s son is not disabled within the meaning of Question and Answer H-6 (81) and is not, therefore, an eligible adult dependent as defined by Article 11 D. (5) of the Employer Benefit Plan. Accordingly, the Respondent is not responsible for the provision of health benefits coverage for the Complainant’s son.
Pertinent Provisions
Article II D. (5) of the Employer Benefit Plan provides:
Article II – Eligibility
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.
Question and Answer (Q&A) H-6 (81) (part 1) provides:
Subject: HEALTH BENEFITS; Disabled Children H-6 (81)
Reference: (50B) II C(5), II D; (74B) II C(5), II D
Question:
Certain dependent children (of any age) are eligible for health benefits if they are mentally retarded or become disabled prior to attaining age 22 and such disability is continuous.
(1) What is the standard for determining whether the dependent child is “mentally retarded or disabled”?
Answer:
(1) A person is “mentally retarded or 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.
Discussion
Article II D. (5) of the Employer Benefit Plan stipulates that health benefits coverage will be provided to dependent children of any age who are mentally retarded or who become disabled prior to attaining age 22, and whose disability is continuous. Q&A H-6 (81), provides that “a person is “mentally retarded or 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 Complainant contends that his son “has been disabled since age 16” and is therefore eligible for health benefits coverage as a disabled adult dependent. The Respondent, however, denies responsibility for the provision of health benefits coverage stating that the Complainant’s son is not disabled within the meaning of Article II D. (5) of the Employer Benefit Plan and of Q&A H-6 (81).
In response to this request for Resolution of Dispute, 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, prior to attaining age 22, 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, mental or psychological impairment which precludes his living or functioning independent of his parents or an institution. Therefore, in accordance with the provisions of Article II D. (5) of the Employer Benefit Plan, 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.
Opinion of the Trustees
The Respondent is not responsible for the provision of health benefits coverage for the Complainant’s son.