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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:316,1982年12月20日
Board of Trustees: Harrison Combs, Chairman; John J. 奥康奈尔,受托人;
Paul R. 迪恩,受托人.
Pursuant to Article IX of the United Mine Workers of America 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 payment of a dismemberment benefit to the Employee by the 雇主 under the terms of the 雇主’s Benefit Plan 3月27日生效, 1978, 在此发表他们对此事的看法.
背景事实
The Employee has worked for the 雇主 from October 1, 1970, 直到现在, except for those periods during which he was unable to work due to the sequelae of a comminuted (broken or crushed into small pieces) fracture of the lower right leg which he sustained at work on December 2, 1975.
Two and one-half weeks after he was discharged from the hospital following the accident, the Employee developed an abscess in his right leg and was readmitted to the hospital for drainage of the abscess. 伤口继续流脓, and it was eventually discovered that he had developed osteomyelitis (infection of the bone) as a result of the accident. He was hospitalized on at least nine different occasions for related treatment. In October 1980, the Employee was again hospitalized and an attempt was made to fuse his ankle. During this hospitalization it was determined that amputation of the leg was necessary due to the osteomyelitis. Subsequently, on 11月12日, 1980, his leg was amputated between his knee and ankle. The Employee was provided with an artificial limb and returned to work for the 雇主 on October 19, 1981.
During the 24-month period immediately prior to October 13, 1980, 雇员已工作超过2年,000 hours in classified employment for the 雇主. 在截肢的时候, 11月12日, 1980, the Employee was receiving Sickness and Accident benefits pursuant to Article XI of the National Bituminous Coal Wage Agreement of 1978.
争端
Is the 雇主 responsible for payment of a dismemberment benefit to the Employee?
各方立场
Position of Employee’s Representative: The 雇主’s insurance policy limits payment for dismemberment to a period of one year from the date of the accident, 不符合工资协议的.
Position of 雇主: The dismemberment benefit is not payable because the Employee’s amputation was caused in part by a bacterial infection and was not due solely to violent, 外部和偶然的手段.
相关的规定
第二条. C. (3) of the 雇主’s Benefit Plan, 3月27日生效, 1978, which provides:
C. 残疾员工
In addition to disabled Pensioners who are receiving pension benefits and are therefore entitled to receive health benefits under paragraph B of this 第二条, health benefits under 第三条 shall also be provided to any Employee who:
(3) Is receiving Sickness and Accident Benefits pursuant to the Wage Agreement.
Life and accidental death and dismemberment insurance shall be provided to Employees described in (3) above.
第三条. B. (1) (c) and (d) of the 雇主’s Benefit Plan, 3月27日生效, 1978, which provides:
B. Life and Accidental Death and Dismemberment Insurance
(1) 积极的员工
Life and accidental death and dismemberment insurance will be provided for Employees, 如第二条所述, A及C部分(3), 按照以下时间表:
(c) If an Employee shall lose two or more members due to violent, 外部和偶然的手段, 该员工将获得12美元,肢解津贴. If an Employee shall lose one member due solely to violent, 外部和偶然的手段, 该员工将获得6美元,肢解津贴. A member for the purpose of the above is (i) a hand at or above the wrist, (ii) a foot at or above the ankle or (iii) total loss of vision of one eye.
(d) Accidental death or dismemberment benefits are not payable if caused in whole or in part by disease, 身体或精神上的虚弱, 尿疹或细菌感染, 疝, 自杀, 故意自残, 起义, 或者战争行为.
第三条. 部分E. (1) of the 雇主’s Benefit Plan, 3月27日生效, 1978, which provides:
E. 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, 视力保健, life and accidental death and dismemberment insurance coverages are as follows:
工作时数 保险期限
24年日历中的雇主 继续从
日期前的一个月 最后的日期
最后的工作 工作
- 2000小时或更长时间 月加余额
12个月
– 500 or more hours but less than 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, 视力保健, life and accidental death and dismemberment insurance coverages while disabled for the greater of (i) the period of eligibility for Sickness and Accident benefits, or (ii) the period as set forth in the schedule in (a) above.
讨论
第三条. B. (1) (c)雇主福利计划, 3月27日生效, 1978, 等于6美元,肢解津贴 will be paid to an Employee who loses a member due solely to violent, 外部和偶然的手段. 根据第三条. B. (1) (d) of the 雇主’s Benefit Plan, a member is defined as a foot at or above the ankle.
It is clear that the Employee’s work-related accident caused him to obtain treatment for his injured leg on nine separate occasions during the period December 2, 1975年至11月12日, 1980.
的资金’ medical staff has reviewed the medical records of this case and determined that the chronic infection which finally necessitated amputation of the Employee’s leg was a direct result of his accident. 因为雇员失去了一名身体成员, 如雇主福利计划所界定, 由于事故, 他有权领取肢解补助金.
受托人的意见
The Trustees are of the opinion that the 雇主 is responsible for the payment of a dismemberment benefit of $6,000元予雇员.