Opinion ID: 2552656
Heading Depth: 3
Heading Rank: 4

Heading: The Joneses' Medical Insurance Claim

Text: On November 4, 1997, Sara gave birth to a son, Tyler. Tyler was born with Down syndrome and other problems. Sara was confined to the hospital for several days following the birth. Within a week of the birth, Justin sent to the Trust forms notifying the Trust that it would need to add Tyler to the Joneses' health insurance. Soon after Tyler's birth, the Joneses began to learn of problems with their health insurance coverage. The hospital began to question the Joneses about it. Also, Freitas told Justin that the Trust had called Janssen with questions about Tyler's condition. In February the. Joneses signed up Tyler for TEFRA, a state insurance plan under which the state paid for Tyler's expenses. From November 4, 1997, to May 31, 1999, TEFRA paid nearly $60,000, of Tyler's expenses. The Trust moved slowly to resolve the question of whether it would provide health insurance to the Joneses. In February Patton sent Sara a letter stating that there was a problem with coverage. This was followed by a letter in late May of 1998 that formally disclaimed coverage. The letter explained that under the trust agreement and federal law, the Trust could not provide health insurance to a nonunion employee without a special agreement. The letter also apologized for the delay in making this determination, blaming the delay on Janssen's failure to cooperate with an audit. At this point the Trust also terminated the participation in the plan of Janssen's other nonunion employees. In August 2000 the Federal Department of Labor sent the Trust a letter of admonishment. The department faulted the Trust for providing benefits to Janssen's nonunion staff without a special agreement in violation of the trust agreement. The department stated that this constituted a violation of ERISA. However, the department concluded that it would not pursue legal action since the Trust had taken measures to prevent similar occurrences in the future.