Opinion of Trustees
Resolution of Dispute
Case No. 88-061
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Employee
Employer
88-061 – March 3, 1989
In Re
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 and hospitalization related to the performance of dental procedures under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s dependent son was seen by a dentist when he was five years old for the treatment of nine teeth which had extensive and advanced carious lesions. The dentist stated that due to the extensive nature of the dental work and the high level of anxiety exhibited by the child, it was necessary to perform the dental treatment, fillings and crown work, under general anesthesia in the outpatient facility of a hospital. The dentist stated that the child exhibited no systemic complications and had no history of medical conditions which influenced his decision to use general anesthesia when the treatment was performed on May 25, 1988.
The Employer paid the dentist for his services up to the scheduled amount under the Dental Plan. It denied payment under the Employer Benefit Plan for the anesthesia services and the outpatient hospital expenses related to the dental procedures performed on the Employee’s son.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges associated with the Employee’s son’s dental treatment?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-061
Page 2
Position of the Employee: The Employer is required to provide health benefits under the Employer Benefit Plan for the anesthesia and hospital charges associated with the Employee’s son’s dental treatment.
Position of the Employer: The Employer is not required to provide health benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges because there was no preexisting medical condition which necessitated hospitalization for the dental procedures and because prior approval was not obtained from the Plan Administrator.
Pertinent Provisions Article III. A. (1)(g) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(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: (3) Physicians’ Services and Other Primary Care
(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. 88-061
Page 3
Article III. A. (1)(g) of the Plan provides that hospital benefits are provided for (1) beneficiaries admitted for the oral surgical procedures described in Article III. A. (3)(e) of the Plan, if hospitalization is medically necessary, and (2) beneficiaries admitted for dental procedures if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.
The Employee’s son received dental fillings and crown work as a hospital outpatient. A Funds’ medical consultant has advised that the dental work performed in this case is not one of the oral surgical procedures identified in Article III. A. (3)(e). The hospital charge is, therefore, not covered under the first section of Article III. A. (1)(g) as cited above.
Benefits are otherwise provided under Article III. A. (1)(g) if hospitalization for dental procedures is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. The dentist conducted the dental work in the hospital because of the Employee’s son’s anxiety and the extensive nature of the dental work. The dentist specifically stated that the hospitalization was not necessitated by a preexisting medical condition. In addition, it is clear that the Employee did not obtain prior approval from the Plan Administrator. Accordingly, benefits are not provided for the hospital charge.
Q&A 81-16 (copy enclosed herein) states that physician services, including anesthesia services, provided in connection with a hospitalization for a non-covered dental procedure may be covered if (1) the hospitalization is medically necessary due to a preexisting medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. As discussed above, the hospitalization of the Employee’s son was not necessitated by a preexisting medical condition. In addition, a Funds’ medical consultant found no evidence that the use of anesthesia in this case was related to the treatment of any otherwise covered medical condition. The treatment received by the Employee’s son was dental work for his dental carries. Accordingly, benefits are not provided for the anesthesia charge.
Opinion of the Trustees
The Employer is not required to provide benefits under the Employer Benefit Plan for the anesthesia and outpatient hospital charges resulting from the Employee’s son’s dental treatment on May 25, 1988.