Opinion of Trustees
Resolution of Dispute
Case No. 84-666
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-666 – September 26, 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 coverage for hospitalization related to the performance of dental procedures under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s oral surgeon has stated that the Employee needed to have 20 teeth extracted, three of which were completely impacted. The oral surgeon stated that the surgery could not be performed in his office because of the great amount of bone removal necessary for the extraction of the three impacted teeth. The extractions were performed in the outpatient facility of a hospital, and the Employee was subsequently fitted with dentures.
The Employer provided coverage for the oral surgeon’s charges and anesthesia services under its Dental Plan. The Employer denied coverage for the related outpatient hospital charges under its Employer Benefit Plan on the basis that the procedures performed are not among the covered oral surgical procedures listed in Article III. A. (3)(e) of the Employer Benefit Plan, the hospitalization was not required due to a preexisting medical condition, and prior approval was not received from the Plan Administrator.
Dispute
Is the Employer responsible for payment of the outpatient hospital charges incurred as a result of the Employee’s dental surgery on January 28, 1988?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 84-666
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Position of the Employee: The Employer is responsible for payment of the outpatient hospital charges resulting from the Employee’s dental surgery because hospitalization was medically necessary given the extent of the surgery.
Position of the Employer: The Employer is not responsible for payment of the outpatient hospital charges resulting from the Employee’s dental surgery because the surgery is not among the covered procedures listed in Article III. A. (3)(e) of the Plan, the hospitalization was not necessary due to a preexisting medical condition, and prior approval was not received from the Plan Administrator.
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) 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
Opinion of Trustees Resolution of Dispute Case No. 84-666
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Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures that are covered under the Plan and states that benefits are not provided for dental services. Under Article III. A. (1)(g) of the Plan, benefits are provided for hospitalization for dental procedures only if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.
A Funds’ medical consultant has reviewed this file and has advised that the surgery performed is not one of the oral surgical procedures covered under Article III. A. (3)(e) of the Plan. The consultant has also advised that the patient’s hospitalization was necessary because of the complexity of the non-covered dental procedure, not because of a preexisting medical condition. Inasmuch as the Employee’s hospitalization was not necessary due to a preexisting medical condition and prior approval was not received from the Plan Administrator, the Employer is not responsible for payment of the hospital charges resulting from the Employee’s dental surgery.
Opinion of the Trustees
The Employer is not responsible for payment of the outpatient hospital charges resulting from the Employee’s dental surgery on January 28, 1988.