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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-396 – November 11, 1987
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 for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse went to a dental surgeon on October 7, 1985 with complaints of chronic facial pain. The dental surgeon determined that she suffered from advanced mandibular atrophy and recommended oral surgery to correct the problem. The dental surgeon has indicated that prior approval was obtained for hospitalization after submitting a comprehensive description of her medical condition, which includes a history of arterial hypertension and hyperthyroidism. On May 1, 1986, the dental surgeon placed reconstructive bone grafts to the left and right posterior mandible, placed a mandibular bone plate staple implant and repositioned the mandibular nerves.
The Employer denied coverage for the oral surgeon’s fees because the surgery was not one of the limited oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan. The Employee claims that the oral surgical procedures should have been covered under the Employer Benefit Plan because the Employee s spouse’s bone loss was congenital in nature and prior approval was obtained. Certain hospitalization benefits were paid by the Employer and have not been disputed by the Employee.
Following the surgery, the Employee’s spouse was fitted with dentures. The Employer denied coverage for the dentures under its Dental Plan. The Employee alleges that new dentures were required as a result of the surgery, and therefore, they should be a covered benefit.
Dispute
Is the Employer responsible for providing health benefits coverage for the Employee’s spouse’s oral surgery and dentures?
Positions of the Parties
Position of the Employee: The Employer is responsible for providing health benefits coverage offer Employee’s spouse’s oral surgery and dentures.
Position of the Employer: The Employer is not responsible for providing health benefits coverage for the dental surgeon’s fee for the Employee’s spouse’s oral surgery because it is not one of the covered oral surgical procedures under Article III. A. (3)(e) of the Employer Benefit Plan. The Employer is not responsible for coverage for dentures under its dental plan because such benefits are limited to once every five years and benefits were provided about two years ago.
Pertinent Provisions
Article III. A. (11)(a) 19. of the 1984 Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services.
Article III. A. (3)(e) of the Employer Benefit Plan states:
(e) Oral Surgery
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)
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Discussion
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. A Funds’ medical consultant has reviewed the information submitted by the dental surgeon and has advised that the surgical procedures performed, bone grafts and an implant, are not among the limited procedures covered under Article III. A. (3)(e). In addition, according to Q&A 81-15 (copy enclosed herein), charges for services for certain dental and oral surgical procedures are covered under the Employer Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. No medical evidence has been submitted to substantiate the position that the patient’s oral surgical procedures were performed as part of the treatment of an otherwise covered illness or injury. Inasmuch as oral surgical procedures performed on the the Employee’s spouse are not among the covered oral surgical procedures listed in Article III. A. (3)(e) and were not performed as part of the necessary treatment for an illness or injury that is otherwise a covered benefit, the professional service fees are not covered under the Employer Benefit Plan.
The Employer has waived the prior approval requirement for hospitalization benefits in this case based upon a determination that the outpatient hospital setting was appropriate and necessary due to the Employee’s spouse’s pre-existing medical conditions. Consequently, certain hospitalization benefits were paid by the Employer. Professional fees for the oral surgery were not included in the charges which the Employer agreed to pay.
With respect to the Employee’s claim that his spouse’s dentures are a covered benefit, Article III. A. (11) of the Employer Benefit Plan specifically excludes coverage for dental services under the Plan. Moreover, inasmuch as dental benefits are provided under Article XX-A of the Coal Wage Agreement, and the Trustees have authority to resolve disputes involving benefits established by Article XX only, the Trustees may not address disputes concerning dental plan benefits.
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits for the Employee’s spouse’s oral surgery.