Opinion of the Trustees ROD Case No. 52
Page 1
December 11, 1979
(Opinion issued in letter form; name and address deleted)
Re: Resolution of Dispute Case No. 52
Pursuant to Article IX of the UMWA 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the U.S. Department of Labor, the Trustees have received the question of coverage for treatment of Temporomandibular Joint Dysfunction for an Employee’s dependent son. Their opinion is issued in Question and Answer form as follows:
1978 Contract Question and Answer #115
Subject: Oral Orthopedics
Question: Is treatment for an oral orthopedic problem, such Temporomandibular Joint Dysfunction a covered benefit when treatment is rendered by a specialist, such as an orthopedist or an oral surgeon?
Answer: Yes. If the treatment is rendered by an oral surgeon, prior approval must be obtained from the Trustees.
The Employee’s dependent son underwent surgery for the resection of the prognathic mandible as treatment to correct a long-standing Temporomandibular Joint Dysfunction (T.M.J. Syndrome) problem. The resection of a prognathic mandible is not a covered benefit, according to 1978 Contract Q&A #48, unless it is performed as part of a treatment for an illness or an injury which is otherwise a covered benefit. In this case, by virtue of Q&A-#115, treatment of T.M.J. Dysfunction is a covered benefit. Therefore the surgical intervention (i.e., resection of the prognathic mandible) provided as treatment for T.M.J. Dysfunction for the Employee’s dependent son, would be a covered benefit.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
Opinion of the Trustees ROD Case No. 52
Page 2 _________________________ Paul R. Dean, Trustee