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OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, 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 benefits for oral/dental surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s family physician referred the Employee to an oral surgeon because of increasing jaw pain and difficulty in eating due to multiple teeth problems. The oral surgeon’s diagnosis was aleveolar atrophy (atrophy of the jaw) and a fistula and lesions of the mouth. The surgeon recommended that the Employee undergo a maxillary and mandibular bone graft, excisions of the multiple lesions in his mouth, and a closure of the nasal/astral fistula. These procedures, as well as the removal of the affected teeth, were performed on May 6, 1991 under general anesthesia while the Employee was an outpatient at the local hospital. The oral surgeon stated that the hospital setting was necessary due to the patient’s anxiety and the severe infection.
The Employer denied coverage under the Employer Benefit Plan for the surgeon’s bill, the anesthesiologist’s bill and the hospital bill. The Employer did however, provide limited benefits for the tooth extraction under the dental portion of the Plan.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the expenses in connection with the Employee’s oral surgery on May 6, 1991?
Positions of the Parties
Employee
Employer
88-565 – July 15, 1992
Opinion of Trustees Resolution of Dispute Case No. 88-565 Page 2
Position of the Employee: The Employer is required to provide benefits under the Employer Benefit Plan for the Employee’s oral surgery and related expenses because the surgery was done in connection with a medical problem and was not a dental service.
Position of the Employer: The Employer is not required to provide benefits under the Employer Benefit Plan for expenses in connection with the Employee’s oral surgery because the surgical procedures are not among those listed as eligible in Article III. A. 3.(e), and there is no evidence of a pre-existing medical condition that would necessitate that the surgery be performed in a hospital setting rather than a doctor’s office.
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) 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
Opinion of Trustees Resolution of Dispute Case No. 88-565 Page 3
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 contained in this file, including the history and physical examination and the letter from the oral surgeon and the letter from the Employee’s attending physician, and has determined that the surgery performed was not among the covered surgeries under Article III. A. 3. (e) of the Employer Benefit Plan.
Under Article III. A. (1)(g) of the Plan, benefits are provided for hospitalization for dental procedures only if necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. As an example, pre-existing conditions such as heart disease, hypertension, diabetes or chronic obstructive pulmonary disease (COPD) could put beneficiary at significant risk of developing complications that could result in further injury, damage or loss if the dental services (covered or non-covered) were performed in a less controlled environment. The Funds’ medical consultant has advised that there is no documentation of a pre-existing medical condition that would have necessitated outpatient hospitalization for these dental procedures. Therefore, the requirements for hospitalization under Article III. A. (1)(g) were not met, making the use of the hospital facilities ineligible in this case.
Therefore, since the oral surgery performed in this case is not one of the covered services listed in Article III. A. (3)(e), nor part of the treatment of an illness or injury otherwise covered the Plan, the surgery charge would be ineligible under the terms of the Employer Benefit Plan. Additionally, since there is no evidence of a pre-existing medical condition requiring use of the hospital facilities, the Employee’s hospital charges do not meet the eligibility requirements as outlined in Article III. A. (1)(g).
Opinion of the Trustees
The Employer is not required to provide health benefits under the terms of the Employer Benefit Plan for the Employee’s oral surgery and related hospital charges incurred on May 6, 1991.
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