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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-397 – September 12, 1991
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 implants under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse’s physician referred her to an oral surgeon who specializes in implant dentistry because she was unable to wear her conventional upper dentures. The physician has stated that the Employee’s spouse was unable to maintain a normal healthy diet and had unspecified psychological difficulties as a result of her dental problems. The oral surgeon evaluated the Employee’s spouse and diagnosed her as having severe maxillary (upper jaw) atrophy and resorption. The treatment he recommended was that she have her upper dentures replaced with dental implants. On July 30, 1990, in preparation for the dental implant surgery, the Employee’s spouse underwent a maxillary osteoplasty to smooth the sharp, spiny projections found on her jawbone. On August 20, 1990, the Employee’s spouse underwent surgical reconstruction of the maxillary arch with the placement of a complete subperiostial implant.
The Employer denied coverage under the Employer Benefit Plan for the dental implant surgery because it is not among the limited oral surgical procedures covered under Article III. A. (3)(e) of the Plan and because the Plan specifically excludes benefits for dental services and dental prosthetic devices. The Employer has stated that it paid any allowable charges associated with the dental treatment under its Dental Plan, but denied benefits for the dental implant because implantology is specifically excluded under its Dental Plan.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s dental implant surgery because it was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s dental implant surgery because such treatment is a dental service and dental services are not covered under the Plan. In addition, the Employer’s Dental Plan specifically excludes benefits for dental implantology.
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. (11) (a) 19. of the Employer Benefit Plan, as well as Q&A 81-15 (copy enclosed herein), indicate that benefits are not provided for dental services except when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. The Employee’s spouse’s dental implant surgery was performed in the oral surgeon’s office; it was not performed in a hospital, as required pursuant to Q&A 81-15. In addition, Article III. A. (7) (a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.
Article III. A. (3)(e) of the Employer Benefit Plan provides benefits for certain limited oral surgical procedures; however, since the dental implant surgery performed on the Employee’s spouse does not involve one of these limited surgical procedures, it does not qualify for coverage under this provision. Accordingly, the Employer is not required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s dental implant surgery.
Opinion of the Trustees
The Employer is not required to provide health benefits under the Employer Benefit Plan for the Employee’s spouse’s dental implant surgery.