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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 02-040
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
As a result of dental work (four teeth extracted and braces applied), the Complainant’s spouse states that her jaw was moved out of alignment and this caused her to have frequent migraine headaches for which she sought relief at the emergency room. On September 10, 2003, she underwent surgery to have her jaw realigned. According to the Complainant’s spouse, following the corrective jaw surgery, her jaw was moved further out of alignment. The Complainant’s spouse states that she experienced more pain after the September 10, 2003, surgery than prior to the surgery.
The Complainant’s spouse requested approval of another surgery to adjust her jaw alignment and facial profile. That request was denied by the Respondent. The surgery would include reconstruction of midface; removal of implant; and reconstruction of mandibular rami (lower jaw).
Dispute
Is the Respondent required to provide coverage for the Complainant’s spouse’s proposed oral surgery to adjust her jaw alignment and facial profile?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide coverage for the Complainant’s spouse’s proposed oral surgery because it has been deemed medically necessary by the Complainant’s spouse’s oral surgeon. The proposed surgery is necessary to correct a previously covered surgery that was not performed correctly.
Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s spouse’s proposed oral surgery because the procedures are not included in the list of oral surgical procedures covered by Article III A (3) (e) of the Employer Benefit Plan. Moreover, the proposed procedures are not for the treatment of an illness or injury that is otherwise a covered benefit. Finally, the proposed procedures are cosmetic in nature (repositioning and re-contouring the facial bones).
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states, in pertinent part:
ARTICLE III BENEFITS
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. . . .
Article III. A. (3) (e) states:
ARTICLE III BENEFITS
A. Health Benefits
(3) Physicians’ Services and Other Primary Care
(e) Oral Surgery
Benefits are not provided for dental services. However, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon.
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem.
Biopsy of the oral cavity
Dental services required as a direct result of an accident
Discussion
The Introduction to Article III of the Employer Benefit Plan limits covered services to those which are medically necessary for the diagnosis and treatment of an illness or injury and which are given at the appropriate level of care. Article III A (3) (e) limits covered oral surgery to those procedures that are specifically listed.
The Funds’ Medical Director reviewed the documentation, which includes the Complainant’s spouse’s dental and oral surgical records dating back to March 8, 2001. Taking into consideration the Complainant’s spouse’s past oral surgical procedures, the Medical Director has determined that the proposed oral surgical procedures do not constitute a treatment for an illness or injury that is otherwise a covered benefit of Article III of the Employer Benefit Plan. The Medical Director further concluded that the proposed oral surgical procedures are not among the limited oral surgical procedures covered by Article III A (3) (e) of the Employer Benefit Plan.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide medical benefits for the Employee’s spouse’s proposed oral surgery.