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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-142 – September 13, 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 for treatment provided by an orthodontist for an Employee’s spouse under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse was seen by an orthodontist for complaints of popping and clicking of the jaw joints, headaches, tenderness and spasms of the jaw muscles, occasional locking of the jaws, limitation of jaw movements, teeth grinding and difficulty sleeping. The orthodontist states that she has an uneven bite on the back teeth, crowded upper and lower front teeth, a deep bite and four wisdom teeth forming. He has proposed an orthodontic treatment plan that includes tooth extractions and the application of orthodontic braces to improve her bite and thereby relieve pressure within the temporomandibular joint. The Employer denied health benefits coverage for the Employee’s spouse’s proposed treatment.
Dispute
Is the Employer required to provide health benefits for the treatment proposed by the Employee’s spouse’s orthodontist?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for the Employee’s spouse’s proposed treatment because she is being treated for a medical problem rather than a dental or cosmetic problem, and such treatment is covered under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide health benefits for the proposed treatment because there is no medical evidence of temporomandibular joint dysfunction and orthodontic treatment is not covered under the Employer Benefit Plan.
Pertinent Provisions
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. Among those procedures is treatment for temporomandibular joint dysfunction under certain circumstances. Q&A 81-88 (copy enclosed herein) further indicates that the only two instances in which benefits are provided for treatment of temporomandibular joint dysfunction are when treatment involves (1) the use of corrective external appliances or (2) corrective surgery to specifically reorient the temporomandibular joint.
The Employer contends that there is no medical evidence of temporomandibular joint dysfunction and that the proposed orthodontic treatment is not covered under the terms of the Employer Benefit Plan. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that the Employee’s spouse’s proposed treatment is not one of the oral surgical procedures covered under Article III. A. (3) (e) of the Plan.’ According to the consultant, there is no medical documentation of temporomandibular joint dysfunction, and the proposed orthodontic treatment is primarily intended to correct the Employee’s spouse’s bite problem.
According to Q&A 81-15 (copy enclosed herein) charges for dental and oral surgical procedures, including “orthodontics,” may also be covered under the Employer Benefit Plan if the procedure is performed in a hospital as part of the treatment for an illness or injury that is otherwise a covered benefit. The medical consultant has advised that there is no medical documentation that would suggest the proposed orthodontic treatment is necessary as part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan.
Since the treatment proposed by the Employee’s spouse’s orthodontist is neither one of the covered oral surgical procedures listed in Article III. A. (3) (e) nor part of the treatment for an illness or injury that is otherwise a covered benefit as discussed in Q&A 81-15, such treatment is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide health benefits for the treatment proposed by the Employee’s spouse’s orthodontist.