Opinion of Trustees
Resolution of Dispute
Case No. 84-447
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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-447 – January 5, 1988
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 orthodontist has diagnosed the Employee as having maxillary sagittal hypoplasia, mandibular sagittal hyperplasia, severe malocclusion and transverse hyperplasia of the maxilla. He characterizes the malocclusion as a severe skeletal Class III relationship of the maxillary and mandibular jaw bones which requires correction to help the teeth function properly, to prolong their longevity and to improve mastication. He placed orthodontic appliances and referred the Employee to an oral surgeon for orthognathic surgery. The Employee’s request for prior approval for sagittal mandibular and Leforte I maxillary osteotomies with an internal rigid fixation to correct the malocclusion was denied by the Employer.
The Employee contends that the orthognathic surgery is medically necessary and that it should be a covered benefit as he was an active miner when he first attempted to get prior approval for the surgery.
The Employer stated that that Employee’s proposed oral surgical procedures are not among the limited oral surgical procedures covered under the Employer Benefit Plan. Therefore, the proposed oral surgery and any hospital charges related to it are not covered benefits.
The Employer further stated that although the limited oral surgical procedures are covered in accordance with a fixed fee schedule under the Employer’s Dental Plan, because the Employee is presently on layoff status, his dental coverage is terminated and will not be reinstated until he returns to active employment with the Employer.
Dispute
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Is the Employer responsible for the provision of health benefits coverage for the oral surgeon’s fee and for the hospitalization charges for the Employee’s proposed oral surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s proposed oral surgery because it is medically necessary, and the Employee was an active miner at the time he first requested prior approval for it.
Position of the Employer: The Employer is not responsible for the provision of health benefits for the oral surgeon’s fee and the related hospital charges because the proposed surgery is not one of the covered oral surgical procedures under Article III.A. (3)(e). The Employer is not responsible for the provision of dental benefits under the Employee’s Dental Plan because he is presently on layoff status and his dental coverage is terminated.
Pertinent Provisions Article III.A. (1)(g) of the Employer Benefit Plan states:
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3)(e) provided hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a preexisting medical condition, and prior approval is received from the Plan Administrator.
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)
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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 orthodontist and the oral surgeon and has advised that the oral surgical procedures outlined therein, sagittal mandibular and LeForte I maxillary osteotomies with an internal rigid fixation, are not among those procedures covered by Article III. A. (3)(e).
In addition, according to Q&A 81-15 (copy enclosed herein), certain charges for services for 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. Again, no evidence has been submitted to establish that this surgery is medically necessary to treat an otherwise covered medical problem or illness. The orthodontist described dental problems such as a severe malocclusion and a difficulty with mastication; he did not state that either problem was related to a medical condition which needs to be treated by the surgery in question.
Article III. A. (I)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization for oral surgical procedures when the admission is for one of the oral surgical procedures listed in Article III. A. (3)(e). That Article also states that inpatient hospital benefits are provided when, because of beneficiary’s preexisting medical condition, hospitalization for a dental procedure is necessary and prior approval has been received from the Plan Administrator. A Funds’ medical consultant reviewed information submitted by the Employee’s orthodontist and oral surgeon and found no evidence of a preexisting medical condition that would indicate that hospitalization was necessary.
Inasmuch as the oral surgical procedures performed on the Employee are not among the covered procedures under Article III. A. (3)(e) and were not performed as part of the treatment for an otherwise covered benefit, as discussed in Q&A 81-15, the oral surgeon’s fee is not covered under the Employer Benefit Plan. Furthermore, inasmuch as the Employee’s hospitalization would not be necessitated by a preexisting medical condition, coverage under Article III. A. (1)(g) of the Employer Benefit Plan has been correctly denied.
Dental benefits are provided under Article XX-A of the Coal Wage Agreement. The Trustees have authority to resolve disputes only involving benefits established by Article XX. Therefore, the Trustees may not address disputes concerning Dental Plan benefits.
Opinion of the Trustees
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The Employer is not responsible for payment of the charges related to the professional services or the hospitalization for the Employee’s oral surgery under the terms of the Employer Benefit Plan.