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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; 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 coverage for outpatient hospitalization for oral surgery under the terms of the Employer Benefit Plan.

Background Facts

On March 27, 1989, the Employee underwent surgery to remove all of his upper teeth and his lower right and left third molars due to periodontitis. The Employer provided coverage for the oral surgeon’s charges and anesthesia services under its Dental Plan. The Employer denied coverage for the related outpatient hospital charges under the Employer Benefit Plan on the basis that the procedures performed are not among the covered oral surgical procedures listed in Article III. A. (3)(e) of the Employer Benefit Plan, the hospitalization was not necessary due to a pre-existing medical condition, and prior approval was not received from the Plan Administrator.

Dispute

Is the Employer required to provide benefits under the Employer Benefit Plan for the outpatient hospital charges associated with the Employee’s oral surgery?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits under the Employer Benefit Plan for the hospital charges associated with the Employee’s oral surgery.

Position of the Employer: The Employer is not required to provide benefits under the Employer Benefit Plan for the outpatient hospital charges because the operation is not one of the oral surgical procedures covered under Article III. A. (3)(e), because there was no pre-existing

Employee
Employer
88-291 – July 25, 1990

Opinion of Trustees Resolution of Dispute Case No. 88-291 Page 2

medical condition that necessitated hospitalization for the dental procedures, and because prior approval was not obtained from the Plan Administrator.

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 pre-existing medical condition and prior approval is received from the Plan Administrator.

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

Discussion

Opinion of Trustees Resolution of Dispute Case No. 88-291 Page 3

Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures that are covered under the Plan and states that benefits are -not provided for dental services. Under Article III. A. (1)(g) of the Plan, benefits are provided for hospitalization for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.

A Funds’ medical consultant has reviewed this file and has advised that the procedure performed was dental in nature and is not one of the limited oral surgical procedures covered under Article III. A. (3)(e) of the Plan. The consultant has also advised that there is no documentation of a pre-existing medical condition that would have necessitated hospitalization for this procedure.

Inasmuch as the Employee’s hospitalization for a dental procedure was not necessitated by a pre- existing medical condition, and prior approval was not received from the Plan Administrator, the Employer is not required to provide benefits for the hospital charges.

Opinion of the Trustees

The Employer is not required to provide benefits for the outpatient hospital charges resulting from the Employee’s oral surgery on March 27, 1989.