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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-217 – February 15, 1990
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 dental implant surgery under the terms of the Employer Benefit Plan.
Background Facts
In June 1987, the Pensioner’s spouse had an intrabony dental implant system placed to help secure an ill-fitting lower denture. Her oral surgeon states that the original implant system was not tolerated, and it had to be removed. In December 1988, she had new intrabony dental implants placed on the mandible.
The Employer provided benefits for the implant system in 1987. The Pensioner therefore contends that the Employer should provide benefits for the replacement procedure under the Employer Benefit Plan.
Dispute
Is the Employer required to provide health benefits for the Pensioner’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide health benefits for the Pensioner’s spouse’s dental implant surgery because benefits were provided for dental implant surgery in the past.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s spouse’s dental implant surgery because it is not among the limited oral surgical procedures covered under the Employer Benefit Plan and because there is no evidence that the surgery is part of an otherwise covered treatment, as discussed in Q&A 81-15. Furthermore, because the Plan specifically excludes benefits for dental prosthetic devices, it is the Employer’s position that dental implants are also not covered.
Pertinent Provisions
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
Article III. A. (7) (a) 1. of the Employer Benefit Plan states:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
Article III. A. (11) (a) 19. of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
…
19. Dental services.
Discussion
Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. According to Q&A 81-15 (copy enclosed herein), charges for dental and oral surgical procedures may also be covered under the Employer Benefit Plan only when the procedures are performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. Dental services are otherwise excluded under Article III. A. (11) (a) 19. of the Plan. In addition, Article III. A. (7) (a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.
A Funds’ medical consultant has reviewed this case and has advised that the implant procedure in question is not one of the oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan. The medical consultant has further stated that there is no medical evidence that the implant surgery was necessary as part of the treatment of an illness or injury that is otherwise a covered benefit. Therefore, the Employer is not required to provide benefits under the Employer Benefit Plan for the surgical placement of the Pensioner’s spouse’s dental implants. The fact that the Employer may have paid benefits for a procedure in the past does not make the procedure a covered benefit.
Opinion of the Trustees
The Employer is not required to provide health benefits under the Employer Benefit Plan for the Pensioner’s spouse’s dental implant surgery.