(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees Resolution of Dispute
Case No. 81-244
Pursuant to Article IX 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 your Request for Advisory Opinion concerning coverage of your spouse’s oral surgery under the Employe’s Benefit Plan.
Article III. A. (3) (e) of your Employer’s Benefit Plan specifically excludes benefits for dental services. Under Article III A. (1) (g) of the Employer’s Benefit Plan, benefits are provided for hospitalization for dental procedures only if the hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. According to information provided to the Trustees, your spouse’s periodontal disease was a dental as opposed to a medical problem, and she had no pre-existing medical condition. Because your spouse had no pre-existing medical condition and prior approval was not obtained from your Plan Administrator, your Employer is not responsible for the payment of charges for your spouse’s hospitalization for oral surgery.
Q&A #81-16, attached hereto, provides that physician services, including anesthesia services, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided. Because your spouse did not have an otherwise covered medical condition, benefits are not provided for anesthesia services performed in connection with her dental procedures.
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee ___________________________________
___________________________________
___________________________________
September 8, 1983
Attachment
Paul R. Dean, Trustee