Opinion of Trustees
Resolution of Dispute
Case No. 84-172
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. 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 hospitalization related to performance of a dental procedure under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s 19-year-old daughter was hospitalized for the removal of four (4) fully impacted 3rd molars. The oral surgeon performing the surgery recommended overnight hospitalization due to the duration and depth of general anesthetic required to remove the imbedded teeth. The teeth are in close proximity to the mandibular nerve, giving rise to the possibility of damage to the nerve during removal of the teeth.
According to the admitting hospital physician, the Employee’s daughter has a history of chronic, severe anxiety and was treated with an anti-anxiety medication at the age of eight (8), but has not taken such medication recently. The physical exam at the time of admission was entirely within normal limits except for mild nasal congestion and discharge. The Employer denied payment because there was no underlying condition which made the hospitalization necessary and because prior approval was not obtained.
Dispute
Is the Employer responsible for payment of the hospital charges incurred during the Employee’s daughter’s hospitalization for dental care on February 13, 1986?
Position of the Parties
Employee
Employer
84-172 – July 28, 1986
Opinion of Trustees Resolution of Dispute Case No. 84-172
Page 2
Position of the Employee: The Employer is responsible for payment of the charges resulting from the Employee’s daughter’s hospitalization for a dental procedure.
Position of the Employer: The Employer is not responsible for payment of the charges resulting from the Employee’s daughter’s hospitalization because the admission was not necessary due to a pre-existing condition and prior approval was not obtained.
Pertinent Provisions
Article III A. (1)(g) of the Employer Benefit Plan states in relevant part:
(1) (g) 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.
Discussion
Under Article III A. (1)(g) of the Employer Benefit Plan, benefits are 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.
In this case, the Employee’s 19-year-old daughter was hospitalized for removal of four (4) fully impacted 3rd molars. According to the physician admitting the Employee’s daughter to the hospital, the patient had no other medical problems for which admission was necessary, except for a history of anxiety for which she received medication at an earlier age.
The proximity of the imbedded teeth to the mandibular nerve may have made the dental procedure more complicated or difficult, but it does not constitute a pre-existing medical condition. Although the Employee’s daughter has a past history of anxiety, it does not constitute a pre-existing medical condition which would satisfy the requirements of Article III A (1)(g), in that it does not increase the risk associated with the services rendered. Thus the dental services she received are not part of the treatment of an otherwise covered medical condition. In addition, prior approval from the Plan Administrator was not obtained before the hospitalization for the dental procedure.
Opinion of the Trustees
The Employer is not responsible for the payment of the hospital charges resulting from the Employee’s daughter’s dental procedure.