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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-655 – April 24, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustees; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 coverage for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
On July 19, 1984 the Complainant’s dependent daughter underwent several oral surgical procedures, including on alloplastic augmentation of the mandible. These surgical procedures were undertaken to correct the daughter’s skeletal deformity of the maxilla and mandible described as a hyperplastic maxilla and a severely micrognathic mandible. Prior to and following the surgery, the Complainant’s daughter also required orthodontic services (i.e., braces) to facilitate the surgical correction.
Dispute
Is the Employer responsible for payment of the charges resulting from the alloplastic mandibular augmentation performed on the Complainant’s daughter?
Position of the Parties
Position of the Complainant: The Employer is responsible for all charges related to the alloplastic mandibular augmentation.
Position of the Employer: The alloplastic mandibular augmentation is not one of the specific oral surgical procedures listed in the Employer Benefit Plan and is thus not a covered service.
Pertinent Provisions
Article III A. (3) (e) of the Employer Benefit Plan states:
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)
Fracture of the jaw, including reduction and wiring
Fracture 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 lesions of the oral cavity
Article III A. (11) (a) 19 of the Employer Benefit Plan provides:
(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.
Q&A #81-16 provides:
Subject: Hospitalization and Professional Services for Dental Procedures
References:Amended 1950 & 1974 Benefit Plans and Trusts, Article III, Sections A (1)(a), A (3)(d) and A (11)(a) 19
Question:
1. Is oral surgery a covered benefit?
2. Are dental services a covered benefit?
3. Are hospitalization charges for semi-private room and board related to a non-covered dental procedure covered under the Plan?
4. Are benefits provided for the medically necessary services (enumerated in Article III, Section A(1), (2) and (3)) in connection with hospitalization for a non-covered dental procedure?
5. Are benefits provided for physician services (enumerated in Article III, Section A (3) in connection with a hospitalization for a non-covered dental procedure?
Answer:
1. Yes, if such surgery receives the prior approval of the Plan Administrator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating
o tumors of the jaw
o fractures of the jaw, including reduction and wiring
o fractures of the facial bones
o frenulectomy, when related to ankyloglossia
o temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem
o biopsy of lesions of the oral cavity
2. No
3.&4. No, except when 1) hospitalization is medically necessary because of pre-existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator.
5. No, except for the treatment of a medical condition for which benefits would otherwise be provided.
Discussion
Under Article III A. (3) (e) of the Employer Benefit Plan, benefits are provided for only those oral surgical procedures which are specified therein. Additionally, under Q&A #81-16, services for a dental procedure may be covered under the Employer Benefit Plan when performed in a hospital as part of the treatment of a covered illness or injury or when hospitalization is necessary because of a pre-existing medical condition.
A Funds’ consultant has reviewed the evidence submitted and has concluded that the oral surgery done on the Complainant’s daughter is not one of the procedures listed in Article III A. (3) (e) of the Plan. He further advised that the surgery cannot be considered as part of the treatment of an otherwise covered medical condition, nor can the hospitalization be deemed necessary because of a pre-existing medical condition. Under usual circumstances, the Employer would thus not be required to provide coverage for this surgery. However, because the Complainant requested and received prior written assurances of coverage for these procedures from the Employer’s insurance carrier, the Trustees have determined that the Employer should be responsible for the charges relating to these procedures.
Also included in the materials submitted by the Complainant was an Explanation of Benefits denying coverage for the orthodontic services provided to the Complainant’s daughter. The Employer’s response did not address these services. The Trustees note, however, that Article III A. (11) (a) 19 of the Employer Benefit Plan specifically excludes coverage for dental services. Orthodontics, according to Dorland’s Medical Dictionary, is the branch of dentistry which deals with the development, prevention and correction of irregularities of the teeth and malocclusion, and with associated facial abnormalities. Orthodontic treatment is therefore considered a dental service and is not a covered benefit under the Employer Plan.
Opinion of the Trustees
The Employer is responsible for any charges relative to the alloplastic mandibular augmentation performed on the Complainant’s daughter on July 19, 1984, but is not responsible for the orthodontic services provided to the daughter prior to and following the surgery.