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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-676 – March 25, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; 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 dental services under the terms of the Employer Benefit Plan.
Background Facts
In October 1981, the Employee’s spouse was injured in an automobile accident. On November 1, 1981, she was seen in a hospital emergency room complaining of headaches and pain in the right temporomandibular joint (TMJ). No abnormalities were identified in x-rays of the skull and mandible. The treatment plan consisted of heat to the jaw, soft diet and aspirin as needed for pain.
In November 1983, the Employee’s spouse was seen by a physician for headaches. The physician referred her to an ear, nose and throat specialist who examined her on December 13, 1983 and February 15, 1984, and referred her to an orthodontist for evaluation of her jaw. The orthodontist examined her on February 23, 1984 and diagnosed TMJ dysfunction, with an indication that the automobile accident of 1981 was a probable contributing factor. Orthodontic treatment was initiated on April 26, 1984.
Question or Dispute
Is the Employer responsible for providing benefits for the orthodontic services provided the Employee’s spouse?
Position of the Parties
Position of the Employee: The Employer is responsible for providing benefits for orthodontic care the Employee’s spouse needs as a result of an automobile accident.
Position of the Employer: The Employer is not responsible for providing
benefits for the orthodontic services because it is not clear that they are required as the direct result of an accident.
Pertinent Provisions
Article III. A. (3)(e) of the 1981 Employer Benefit Plan states:
(e) Oral Surgery
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 lesions of the oral cavity
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.
Q&A 81-88 states:
Subject: Oral Orthopedics
References: Amended 1950 & 1974 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 surgeon, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for TMJ which involves the insertion of dentures.
Discussion
Under Article III. A. (3) (e) of the 1981 Employer Benefit Plan, benefits are provided for services required to treat TMJ dysfunction when medically necessary for the treatment of an oral orthopedic problem. According to Q&A 81-88, benefits are provided for treatment of TMJ only when the treatment involves the use of corrective external orthopedic appliances or corrective surgery to specifically re-orient the temporomandibular joint. Article III. A. (11) (a) (19) of the Employer Benefit Plan specifically excludes benefits for dental services.
In this case, the Employee’s spouse was diagnosed as having TMJ dysfunction. The banding was accomplished on April 20, 1984 and consisted of banding the teeth to correct the bite. Since bands (or braces) are orthodontic appliances and their installation would therefore constitute orthodontic or dental treatment, they are not a covered benefit under the provisions of the 1981 Employer Health Plan.
Opinion of the Trustees
The Employer is not responsible for providing benefits for the orthodontic services provided to the Employee’s spouse.