Brian,
Hope all is well with you and yours and you are keeping busy. The following is an appeal for a friend of mine who was denied coverage because he is receiving SSDI. The interesting thing is that as you may already know AETNA/UPS has been paying the balance of what SSDI doesn't pay at 80% for Carl Katarzynski as shown on his EOB'S
This is an important issue and I certainly don't want to blow it. Brum and Whitney are the two UPS Corporate minions who were sent up to Chicago in April to meet with me and Carl and Ted. I have taken a certain amount of liberty with my comments and verbiage, as they know me from past experiences. Mr. Brum sarcastically referred to me at our meeting as a legend and I wouldn't want to disappoint him. I don't have much respect for people who make their living denying hard working folks their benefits.
Any suggestions or thoughts would be greatly appreciated. This issue will effect me in September and many more participants in the UPS Health and Welfare Plan in the future.
Later,
Doug
Paul K. Mounts Phone (773) 631-9872
6109 N. Austin Fax 
(773) 763-1962
(773) 763-1962Chicago, IL. 60646
September 01, 2001
Mr. Brian M. Brum
UPS Legal Department
Mr. Dale Whitney
UPS Corporate Benefits
United Parcel Service of America, Inc.
55 Glenlake Parkway, NE
Atlanta, GA. 30328
800-643-4442
(404) 828-6000
(404) 828 7734
Dear Mr. Brum,
My original correspondence relating to my medical coverage with regard to medical services rendered on July 5, 2000, was dated November20, 2000, to Mrs. Nancy Clark a AETNA/UPS Support Consultant. At your meeting with Carl Katarzynski, Ted Clemons, and Doug Chapman on April 22, 2001, you stated that Carmen Borrelli at UPS Corporate in Atlanta was "looking into the Mounts claim situation", and it would be resolved. No response was made by. Mrs. Nancy Clark, or Mrs. Carmen Borelli to the claim I sent via certified mail# P 217-9110530 and signed for by a Marion Alexander. That correspondence has gone unanswered from November 20, 2000 until the present. This in and of itself is a violation of ERISA LAW as untimely and a ludicrous, incompetent, illogical, inept, attempt at confusing and confounding a Plan Participant in order to avoid paying a credible claim for benefits.
This letter is a formal appeal of your determination of the above mentioned claim as stated in your July 11, 2001 denial of benefits to me which stated in part "According to the documents you submitted, you are covered by Medicare and thus not eligible for benefits under the plan" which is the UPS Health Program for Retirees (plan no. 503) EIN: 95-1732075 Plan Code 607497-M referred to as (R4) which I would have been able to participate in if my Local 705 Teamsters Pension was dealt with in a proper manner at the time of my becoming disabled from injuries suffered while working for UPS. Your decision is without merit and is arbitrary and capricious at best.
In Crocco v. Xerox Corp., F. Supp. 129 (D. CONN. 1997) held that a self-insured plan may not simply "rubber-stamp" benefit denials made by an outside utilization review firm engaged to contain plan costs. The Court in Crocco found that the plan failed to give a participants claim a "full and fair review" when it relied on its utilization review consultant's decision to permit payment for only thirty (30) days of the participants inpatient psychiatric hospitalization.
Another interesting case was U. S. v. Coyle, 63 F.3d 1239(3rd Cir. 1995) which in and of itself was rather novel and upheld the conviction of the Chief Financial Officer of North American Dental Administrators of among other things, mail fraud and false statements on documents required under ERISA. The mail fraud consisted of retaining undisclosed discounts for the company's account. The false reporting consisted of failing to report such amounts on the Schedule to the Form 5500 prepared by the company. Since the Coyle decision, the Department of Justice and the U.S. Postal Inspectors have investigated at least one other large managed care organization for mail fraud based on the organization's use of the mails to send participants Explanation of Benefits (EOB'S) showing calculation of co-payment amounts based on undiscounted charges.
If I may indulge your patience a little longer, I would like to suggest that courts will not defer to a Plan Administrator's "reasonable" interpretation of ambiguous language, particularly where a Plan Administrator has a financial interest in the outcome. For example, in McConocha v. Blue Cross and Blue Shield of Ohio, 898 F Supp.545 (N.D. Ohio1995) the court held that where an insured plan's terms provided that Blue Cross and Blue Shield was required to pay eighty percent (80%) of the "provider's reasonable charges," it was reasonable to conclude that the participant's co-payment would be ZERO PERCENT (0%) of those same charges. In so holding, the Court deferred to the participant's reasonable expectation that "provider's reasonable charges" would be the actual bill, including discounts. The McConocha court further held that Blue Cross and Blue Shield breached its fiduciary duty not to mislead participants with respect to plan benefits, and that the discounting scheme "was a material fact that should have been disclosed."
Now to address my personal plight. I was forced to take a Disability Pension by IBT Local 705 when in fact I should have received a twenty-five (25) and out full pension and qualified to be a participant in the above-mentioned Plan. Because of collusion between UPS Management in Northern Illinois and the Union to reduce my workman's compensation pay, I was forced to take the Disability Pension that under state law reduced my Workman's Compensation Payments from UPS through Liberty Mutual.
I know you are aware of and have documentation showing that Northern Illinois UPS Management's ethics; integrity, morals and tactics were and probably still are unconscionable and reprehensible with regard to falsifying documents. You know this is true from your meeting with Carl Katarzynski, Ted Clemons, and Doug Chapman on April 22, 2001. Sir, you and Mr. Dale Whitney at your meeting with the above gentlemen guaranteed them that you and UPS would reconcile and correct all previous, present, and future conflicts with any questionable solutions to be for the benefit of the Plan Participants as is your fiduciary responsibility.
I wonder if this type of coercive miss-management has its roots in Atlanta, as it seems to be nation wide? Perhaps you are aware of the following information posted on the Internet,
Robert Waterbury "Case background: August 1997 Teamster/UPS strike. I was a picketer on a strike line against UPS near Sacramento. A UPS Truck that was being driven by management attempted to cross the strike line. I blocked his way out, so the driver 'popped the clutch' and knocked me to the ground. I went to a doctor and was treated for minor injuries. The UPS manager and his buddies claimed that I faked the incident. UPS's insurance carrier (Liberty Mutual) refused to pay the medical bills and notified the California Dept of Insurance that I allegedly committed Insurance-Fraud.
Two years later, June 1999 agents from the Dept of Insurance arrested and beat me in front of my co-workers inside the UPS facility where I work.
During the lengthy trial in late September 2000,Liberty Mutual testified and produced internal documents that I never even filed a claim against with them. At that point it became difficult for the District Attorney to explain to the judge why I was arrested and charged for " Providing a false statement in support of an insurance claim". Never mind that UPS management was caught committing perjury during the trial. Management was unaware that somebody had caught the accident on video. Which clearly contradicts the testimony they had provided to the investigators and during-the-trial.
The judge made several statements during the course of the trial that my arrest and ultimate prosecution was politically motivated. During the trial, Chuck Quackenbush was resigning as Dept of Insurance Commissioner due to his scandalous relationship with insurance companies such as Liberty Mutual. It was obvious that Liberty Mutual had pulled strings to have me arrested on trumped up charges." This is an amazing scenario, especially, when you consider the fact that Liberty Mutual and Aetna are in fact Third Party Providers (TPP) acting at the behest of UPS who is self insured and pulls all the strings and makes all the final decisions.
In my humble opinion I am entitled to UPS Medical and SSDI for the following reasons,
Q. In reviewing the Summary of Benefits document for the R-4 Plan Code 607497-M, there is no reference to the exclusion of participants of the Pension Plan related to IBT Local 705 who finally receive their twenty-five (25) and out pension retroactively and were receiving Social Security Disability.
Response, The Summary Plan Description (SPD), the Plan Documents for the R-4 Plan, the 5500FORMS all appear to conflict with the IBT Local 705 Contract with regards to retirees and violates ERISA Law, ADA Law, the Older Worker's Benefit Protection Act (OWBPA), and HIPAA, the 3103h Portability Act, as well as EEOC regulations in many ways. As a matter of fact UPS should have known I would be receiving Social Security Disability Insurance (SSDI), because of my Social Security Disability as evidenced in Mr. Whitney's letter dated December 13, 1999. At this juncture I might add that an individual on Social Security Disability Insurance (SSDI) CAN NOT get any type of supplement such as Medi-Gap, because of their Disabilities. Mr. Whitney apparently realized there was and is a distinct difference between SSDI and SSMI and the benefits they provide and the rules and laws governing them as stated in his letter.
Q. On page (5) ELIGIBLE CLASS: " Employees represented by the following Locals who retired between the ages of (55) and (65), are not eligible for Medicare, and in a pension plan. Spouses must be under the age of 65 and not eligible for Medicare".
Response, I would point out that Members of the Class from Local 705 could retire at fifty-two (52) with twenty-five years service, which I received because of the DOL/PWBA determination Dated 11/16/1999 Control ID: 199940-14071 that I'm sure you remember. Also Members of the Class from Local 710 can retire at fifty (50) with twenty-five years service. The reference to Medicare is in reference to being sixty-five (65) and receiving Social Security Medical Insurance (SSMI), NOT Social Security Disability Insurance (SSDI).
Q. On page (7) COPAYMENT LIMIT $1,000.00
Response, The amount was highlighted and the $1,100.00 hand written in further indicates a conflict between the Summary of Benefits document for the R-4 Plan Code607497-MI and the actual 1993 through 1997 contract referencing retirees benefits from IBT Local 705 and UPS.
Q. On page (9) ELIGIBILITY PROVISIONS As stated in the Eligibility Provisions & quot; An employee will become eligible on the Eligibility Date (AGE) described on the Summary of Benefits.
Response, I became eligible and UPS in their letter from Mr. Dale Whitney dated December13, 1999 (copy enclosed) stated, "It appears that your dependent spouse is eligible for healthcare coverage, however you will need to contact the UPS Benefits Service Center to determine if you meet eligibility requirements of the Plan." There is no doubt that, Mr. Whitney in the above quote realized that SSDI (Social Security Disability Insurance) is different from SSMI (Social Security Medicare Insurance) at sixty-five (65) years of age. This was a direct response from UPS Corporate Benefits and a Fiduciary under ERISA LAW. Clearly the AETNA and UPS determinations are the same with regard to SSDI.
Q. The Plan Documents are not signed. There is no clear explanation as to how to appeal the denial of benefits. There are no names or references as to whom the fiduciaries are or whom to appeal to. These documents are ambiguous to an extreme. They do not apply to a great many contractual benefits with different Local Unions, which are not, nor ever have had the same contractual benefits.
Response, It is apparent that there is a concerted effort to confuse and confound the Plan Participants and an intentional effort to not have anyone at AETNA or UPS held responsible for their actions. Even the Explanation Of Benefits (EOB'S) we receive are vague and ambiguous, which I might add is a clear violation of ERISA Law.
Q. The1993 through 1997 Plan Documents revised in 1998 to ostensibly cover the 1997through 2002 union contract time frame and resolve other issues are incongruous, inconsistent, arbitrary and capricious at best. The coverage at age fifty-two (52) which I received because of the DOL/PWBA determination Dated11/16/1999 Control ID: 199940-14071, is a prime example and only one of many inconsistencies.
Response, Once again, I will reiterate! It is apparent that there is a concerted effort to confuse and confound the Plan Participants and an intentional effort to not have anyone at AETNA or UPS held responsible for their actions. Even the Explanation Of Benefits (EOB'S) we receive are vague and ambiguous.
The changes that were made were however, significant enough to warrant notification of the changes to all participants, which was never done, and a blatant violation of ERISA LAW.
Q. At this juncture I feel it appropriate to raise the following questions with regard to the 5500 Forms on file with the DOL and IRS for UPS Health Program for Retirees (plan no. 503) EIN: 95-1732075.
For the Plan Year ending December 31, 1995.
On the 5500 form line 13a and b there is a reference to the six-digit LM numbers of Labor organizations covered.
(1) 031841 represent which Local Union?
(2) 015451 represent which Local Union?
(3) 009355 represent which Local Union?
Also on the same page line 7b shows 1,380 retired or separated participants of which I am one (1). Who or what group(s) constitutes the 93,782 participants listed online 7 a (4)? Are they all RETIREES? Are any of these participants on-bargained for participants? Are any of these participants highly compensated? Are any of these participants Part-Timers?
On line 7 (e) "Deceased participants whose beneficiaries are receiving or are entitled to receive benefits." is blank. Its great to know that everyone entitled to benefits under this Plan is alive and well and there are no suffering widows and families.
On line 7 (h) "Number of Participants that terminated employment during the plan year with accrued benefits that were less than 100%vested" is blank. What about those participants who retired with twenty-five (25) years but were not fifty (50) or fifty-two (52) years of age at the time of retirement but were entitled to benefits under the DOL/PWBA determination dated 11/16/1999 Control ID: 199940-14071 that I'm sure you remember? These folks were not 100%vested because of age discrimination and had to wait until they reached the appropriate age. What about the UPS Part Timers in Local 804 covered under the BLUE CROSS BLUE SHIELD alluded to on one of the Schedule A's. The turnover of Part Timer's is legendary.
I find it rather curious that,
Q. MAGNACARE
Q. VALUEBEHAVORIAL
Q. PAIDPRESCRIPTIONS
Q. VISIONSERVICE PLAN
Q. AETNALIFE / CASUALTY
Q. AETNAU.S. HEALTHCARE
Q. BLUECROSS BLUE SHIELD
Q. ALEXANDER& ALEXANDER
Q. KAISERFOUNDATION HEALTH PLAN Inc.
Are all listed in the 5500 Forms as Providers for the UP Health Program in question? Is the implication that The Plan Documents in question are the guidelines for all of the above Provider's? Is it also true then that these 5500Forms also cover UPS Part Timers in Local 804 in New York as they indicate? If so, my question to you as a fiduciary is; how can the Plan Documents in question control and dictate benefits to UPS Retirees and UPS Part Time workers of Local 804, and unspecified possibly non bargained for Participants who all receive completely different Benefits? Paid Prescriptions and AETNA U.S. HEALTHCARE only cover me as a UPS RETIREE. I have no Vision Care or Dental Care. Is there a possibility we Retirees should take up that issue as well?
Another question arises at this point. Would it be possible or conceivable that the Plan Documents and 5500 Forms sent to the DOLand IRS are not the exact copies of those sent to Participants when a Participant requests them? Are the 5500 Forms in error, or are the Plan Documents, and Summary Plan Description in error? There is no parity between any of the Documents governing this Health Plan!
Are the contributions to the Plan on behalf of the participants in various Local Unions equal to those contributions made to individual Taft Hartley Teamster Funds as is required under the provisions of the UPS National Contract and their supplements? Are those equal (matching) contributions related to and enumerated on the 5500 forms as required?
Now sir, If you still have the patience and intestinal fortitude to continue, I will get into the interpretations, rules, protocol, and laws provided by the Social Security Administration in their Social Security Disability Medicare and you 2001 booklet. Specifically on pages,
Q. #12, "If you or your spouse still work or are retired, you may be able to get employer or union health care coverage"
Q. #22, "What if you have employer or union coverage?
Q. #45, "Appeals: You have the right to file an appeal if Medicare does not pay for a covered service you have been given, or if your health plan does not give you a service that you believe should be provided (see pages 46-47)."
Q. #48, "You are protected from Discrimination; every company or agency that works with Medicare must obey the Law. You cannot be treated differently because of your race, color, national origin, disability, age, or sex under certain conditions."
Q. #54, "Question #9 and A: "Sometimes your other insurance pays your health care bills firsthand Medicare pays second."
Q. #58,"Question #15 and A: "What situations give me the right to buy a Medi-gap policy after my open enrollment period ends?"
Q. #59, "employer group health plan that supplemented or paid some of the costs not paid for by Medicare, ends through no fault of your own. For example, the company goes bankrupt."
In my humble opinion, along with the above-mentioned conflicts in the UPS Plan Documents and the Summary Plan Descriptions, and the5500 FORMS, the facts are clear that under ERISA Law, ADA Law, SSDI Law, EEOC Law, the Age Discrimination Laws, the Older Worker's Benefit Protection Act (OWBPA), and the HIPAA, Portability Act 3103h, I am entitled to the continuation of my UPS Medical Coverage until I reach sixty-five (65) years of age and go on Medicare (SSMI).
I find it curious that Management People who are retired are still covered with UPS Medical after they reach sixty-five (65) years of age. In fact, I understand that Drug Prescriptions have been increased for Management Retirees over the last three (3) years. Could it be possible that the fiduciaries in question are in violation of the two-hat rule and are not acting with prudence with regard to management retirees?
Any reasonable person should and would conclude that UPS is saving hundreds of thousands if not millions of dollars when a participant starts receiving Social Security Disability Insurance (SSDI). Many others and me were injured on the job while working for UPS and were on Workman's Compensation when we were forced to retire and seek SSDI. Oh yes, there is one more thing. The denial of Medical Benefits by AETNA/UPS to a Plan Participant in my humble opinion is akin to defrauding the Federal Government namely Social Security Disability Insurance (SSDI) under Social Security Medicare Insurance (SSMI).
I might add that I have much more documentation gathered over the years by many individuals that will corroborate and provide proof that the assertions made above are accurate, truthful and I'm sure will be very enlightening to the proper authorities having jurisdiction over this matter. One small example is the following,
$ An Explanation Of Benefits form (EOB) from UPS/AETNA U.S. Healthcare to participant;
A. Vallone,
2319 Woodsong Trail,
Arlington, TX. 76016-1038
$ ID Number #356-28-6842,
$ Page sequence number # 05507-1MC-C033945,
$ C-S-A-607497-55-953,
$ ICN Number # 06009T,
$ Date Prepared 3/13/01
$ In the REMARKS section, the following is stated,"1-Our records indicate that your coverage terminated before you received services. Claims for expenses incurred after the date coverage terminated cannot be considered unless we receive confirmation, from your employer, that continued coverage applies. You may be entitled to an extension of Benefits if you were TOTALLY DISABLED at the time coverage terminated and if your Plan contains an extension of benefits provision. To claim any extension of benefits that may apply, please send us a statement, from your doctor, giving dates and descriptions of your disability."
You remember Mr. Vallone? He was cut off from his benefits before he turned sixty-five (65) and was double billed for the continued coverage for his wife Sue. Sir, are there other Plan Participants receiving SSDI and AETNA/UPS paying the balances on their bills at eighty percent (80%) as it should be? Mr. Brum, I will reiterate once more that the illustration above, and a preponderance of the other documents in our possession prove that the Plan Documents, the Summary Plan Description, AETNA'S determinations as well as the determination by UPS, and in this situation, your determination in your July 11, 2001, correspondence to me are untimely, are arbitrary and capricious and in conflict with the Plan Documents, Summary Plan Description, the 5500 FORMS, ERISA Law, ADA Law, SSDI Law, EEOC Law, the ADA, Age Discrimination Laws, the Older Worker's Benefit Protection Act (OWBPA), and HIPAA, the Portability Act 3103h.
Others and me similarly situated and on SSDI are entitled to the continuation of UPS Medical Coverage until we reach sixty-five (65) years of age and go on Medicare (SSMI). I am requesting a written response to all the issues and queries raised in the five (5) previous pages of documentation.
To be notified in the event of your denial of this appeal,
Jim Kelly UPS CEO
Office for Civil Rights Office of the Inspector General Bazar Regional Director Chicago DOL/PBWA
Howard L. Marsh Regional Director Atlanta DOL/PWBA
Social Security Disability Medicare Office of Eligibility Administration
Sincerely,
______________________________________________
Paul K. Mounts
DPCSR/PKM
cc: File
D. Brian Hufford
Bob Persak IBT Local 705
Enclosures
