(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees Resolution of Dispute
Case No. 81-363
December 21, 1983
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 Resolution of Dispute concerning Coverage of dental services, anesthesia services, and hospitalization for your spouse under the Employer’s Benefit Plan.
Your spouse was hospitalized for abdominal surgery. Because her abdominal surgery is a covered benefit under the Plan, your Employer is responsible for providing coverage for hospital services related to the abdominal surgery. During this hospitalization Dr. , your spouse’s dentist, following administration of general anesthesia, extracted her remaining teeth and surgically removed an impacted molar.
Article III. A. Sections (3) (e) and (11) 19 establish that, except for certain limited oral surgical procedures, dental services are not covered under the Plan. Q&A 81-16, attached hereto, reiterates that dental services are not a covered benefit under the Plan, and further 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.
Dr. services to your spouse were performed in order to reduce the possibility that the chronic and sub acute infection of her mouth might cause a blood borne infection at the site of the recent abdominal surgery. This does not alter the fact that services performed were dental services and that they are not among the limited number of covered oral surgical procedures. A Funds’ medical consultant has reviewed the medical evidence submitted in this case and has determined that the extractions performed by Dr. constitute dental services which cannot be considered as part of the treatment of an otherwise covered medical condition.
Therefore, your Employer is not obligated to pay for the dental care provided to your spouse, nor for the anesthesia services provided as part of your spouse’s dental care in this instance.
Sincerely, ____________________________ Harrison Combs, Chairman _____________________________ John J. O’Connell, Trustee _____________________________ Paul R. Dean, Trustee