March 1, 1984
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-245
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Resolution of Dispute concerning the level of health benefit coverage for treatment of temporomandibular joint dysfunction.
Under Contract Question and Answer #81-88, attached hereto, treatment of temporomandibular joint dysfunction is not a covered benefit unless the treatment involves the use of a corrective external orthopedic appliance or corrective surgery to specifically reorient the temporomandibular joint. The Employer maintains that your spouse’s appliance was not covered because it is not a corrective external orthopedic device. The Trustees have been advised that the treatment rendered did, in fact, involve the use of a corrective external orthopedic appliance as required in Q&A #81-88. Therefore, the Trustees are of the opinion that the Employer is responsible for the provision of benefits coverage for the treatment of the spouse’s temporomandibular joint dysfunction including payment for the external orthopedic device, in this instance.
Sincerely,
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee
Control Number: 81-88
Subject: Oral Orthopedics
References: Amended 1950 & 1975 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgery, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.