Opinion of Trustees
Resolution of Dispute
Case No. 88-125
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-125 – August 11, 1989
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 oral surgery under the terms of the Employer Benefit Plan.
Background Facts
An orthodontist diagnosed the Employee’s dependent son as having a significant dentofacial deformity – mandibular retrognathism (a receding jaw). The Employee’s son has had orthodontic therapy to correctly align his teeth in preparation for surgery to reposition his lower jaw; bilateral sagittal split osteotomies of the mandible have been recommended. The Employee’s request for prior approval for the proposed oral surgery was denied by the Employer. The Employee contends that coverage should be provided for the oral surgery because his son will develop severe problems without it.
The Employer contends that bilateral sagittal split osteotomies are not among the covered procedures listed in Article III. A. (3)(e) of the Employer Benefit Plan and that the medical information provided does not indicate a preexisting medical condition which would satisfy the requirements of Article III. A. (1)(g) of the Plan. The Employer therefore maintains that coverage for the proposed oral surgery and related hospitalization was properly denied.
Dispute
Is the Employer responsible for providing health benefits coverage for the Employee’s son’s proposed oral surgery and the related hospitalization?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-125
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Position of the Employee: The Employer is responsible for providing health benefits coverage for the Employee’s son’s proposed oral surgery because such – surgery is necessary to prevent problems that may develop because of the misalignment of his jaws and teeth.
Position of the Employer: The Employer is not responsible for providing health benefits for the Employee’s son’s proposed oral surgery because it is not one of the covered oral surgical procedures under Article III. A. (3)(e). The Employer is not responsible for providing health benefits coverage for the related hospitalization charges because a preexisting medical condition has not been documented as required under Article III. A. (1)(g) of the Employer Benefit Plan.
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
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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 in this case and advised that the proposed oral surgical procedure is not among those procedures covered under Article III. A. (3)(e). The consultant has also advised that the proposed surgery is orthodontic in nature in that it is intended to correct an overbite. According to Q&A 81-15 (copy enclosed herein), certain other dental and oral surgical procedures, including “orthodontics,” may be 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. The medical consultant has advised that the documentation provided does not establish that the proposed surgery is medically necessary to treat an otherwise covered medical condition.
Article III. A. (1)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and when prior approval has been received from the Plan Administrator. The medical consultant has advised that there is no evidence of a preexisting medical condition.
Since the patient’s proposed oral surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) or part of the treatment for an illness or injury which is otherwise a covered benefit, the professional services fees are not covered. Because the surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a preexisting medical condition, the patient’s proposed hospitalization does not meet the requirements for coverage under Article III. A. (1)(g).
Opinion of the Trustees
The Employer is not responsible for providing health benefits coverage for the Employee’s son’s proposed oral surgery and hospitalization.