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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 240, November 24, 1981
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article 12 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 coverage of dental services and hereby render their opinion on the matter.
Background Facts
The Employee’s son, aged 16, was injured in an automobile accident on May 11, 1980, sustaining fractures of the mandible, Two front teeth also were broken. Emergency services provided immediately following the accident included reduction of the fractures and wiring of the jaws, which remained in place for a period of six weeks. The Employer’s Plan covered the emergency treatment and follow-up services related to it. The insurance carrier, however, has denied coverage of subsequent endodontic services provided by a dentist and an oral surgeon consisting of root canal surgery and x-rays related to ultimate restoration of the two front teeth.
Question or Dispute
Is the Employer responsible for payment of the charges for the endodontic services related to the restoration of the patient’s damaged front teeth?
Position of Parties
Employee: The Employee feels that refusal of payment by the insurance carrier for the dental restorative (endodontic) services was in error because they were the direct result of the automobile accident.
Employer: The insurance carrier bases denial of coverage for the endodontic services on Q&A #48.
Pertinent Provisions
Article III, A (3) (e) of the Employer’s Plan which provides as follows:
“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)”
Article III, A (10) (a) (19) of the Employer’s Plan which specifically lists dental services as excluded from coverage.
Q&A #48
“Subject: Dental and Oral Surgical Procedures
“References: Revised 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (g) and Section # (3) (e)
“Question:
“Are the following dental and oral surgical procedures covered under the 1978 Agreement?
a. extraction of teeth?
b. gingivectomy, alveolectomy, operculectomy:
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?
“Answer:
“The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during treatment for an auto accident involving extensive facial damage; (2) the extraction of teeth during treatment for cancers of the head and mouth; or (3) the insertion of a mandibular bone staple to repair a fractured jaw.
“Except as provided in the above paragraph, none of these seven procedures is covered under the 1978 Agreement.
“Dental services are specifically excluded from coverage, except for those listed under the Oral Surgery benefit in Sect. A (3) (B). These include surgical treatment for:
“- tumors of the jaw
“- fractures of the jaw, including reduction and wiring
“- fractures of the facial bones
“- frenulectomy, when related to ankyloglossia (tongue tie).”
Discussion
Under Article III, A (3) (e) of the Employer’s Plan, dental services are specifically excluded as a covered service. Under Q&A #48, certain dental and oral surgical procedures are covered, but only when performed in a hospital as part of treatment for an illness or injury which is a covered benefit.
The specific services in dispute in this case are those related to endodontic care provided on December 4, 1980 and December 18, 1980, approximately seven months after the Employee’s son’s accident. The endodontic care included root canal therapy and x-rays preparatory to later restoration of the two previously broken teeth with porcelain crowns. Since these services were not part of the emergency treatment of the traumatic injuries, they are excluded from coverage by the Employer’s Plan.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment for the endodontic services provided to the Employee’s dependent son.