Opinion of Trustees
Resolution of Dispute
Case No. 84-105
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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-105 – December 18, 1985
Board of Trustees: Joseph Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 the provision of health benefits coverage for anesthesia services for a dental procedure under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s daughter, who is known to have cerebral palsy and an active seizure disorder, was hospitalized on December 14, 1984 for dental services. The Employer has denied payment for the anesthesia charges resulting from this care.
Dispute
Is the Employer responsible for payment of the anesthesia charges incurred during the Employee’s daughter’s hospitalization for dental care on December 14, 1984?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of the anesthesia charges resulting from the Employee’s daughter’s hospitalization for dental rehabilitation.
Position of the Employer: Coverage for anesthesia services was denied because the Employee’s daughter’s hospitalization for dental surgery was not related to the treatment of her pre-existing medical condition, and the anesthesia services were not part of the treatment for an otherwise covered medical condition.
Pertinent Provisions
Article III. A. (1) (g) and III. A. (3) (d) of the Employer Benefit Plan state in relevant part:
Opinion of Trustees Resolution of Dispute Case No. 84-105
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(1) (g)
(3) (d)
Oral Surgical/Dental Procedures
Benefits are also provided for a beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.
Anesthesia Services
Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, who is not an employee of, nor compensated by, a hospital, laboratory or other institution.
Discussion
Article III. A. (1) (9) provides benefits for hospitalization for dental procedures only if such hospitalization is necessary due to a pre-existing medical condition and when prior approval has been received from the Plan Administrator, as it was in this case.
Article III. A. (3)(d) establishes the conditions under which anesthesia services are considered a covered benefit. Anesthesia for a dental procedure qualifies under this provision if it is necessary to assure proper medical management, control, or treatment of the patient in light of the underlying medical condition.
The Funds’ consultant who reviewed this case concluded, based on medical information supplied by the beneficiary’s physician, that the hospitalization and general anesthesia were necessary due to the beneficiary’s pre-existing medical condition. In her dentist’s opinion, the beneficiary’s cerebral palsy and seizure disorder prevented the oral surgeon from performing the required dental rehabilitation safely and effectively with local anesthesia. The use of a general anesthetic was therefore necessary in this case to permit the required services and to avoid harm to the patient. Under these circumstances, the pre-existing medical condition requirement of Article III. A. (1) (g) is satisfied. In addition, since the required anesthesia was provided in accordance with Article III. A. (3) (d), it is a covered benefit under the terms of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for the payment of the anesthesia charges resulting from the Employee’s dependent’s dental care on December 14, 1984.