OPINION OF TRUSTEES
______________________________________________________________________________
In Re
Complainant: Retiree
Respondent: Employer
ROD Case No: 11-0135 – October 31, 2016
Trustees: Michael H. Holland, Marty D. Hudson, and Joseph R. Reschini
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
The Complainant received injuries to his mouth on June 23, 2012, while repairing his automobile. The accident fractured, displaced and/or repositioned three teeth (numbers 8, 9, and 10). The Complainant was examined and treated by an endodontist immediately following the accident and was referred to a dentist for a treatment plan to coordinate repair work with the endodontist.
Treatment for the injuries progressed over a three-year period to allow healing in the presence of diabetes mellitus and included root canals and crowns. The Respondent covered the dental work performed in 2012 and 2014, but is denying payment for the work performed in 2015 as dental work unrelated to the accident and, therefore, not a covered benefit.
Dispute
Is the Respondent required to provide benefits for the dental work that the Complainant received in 2015 on teeth 8, 9, and 10?
Positions of the Parties
Position of the Complainant: The Complainant’s dental work that was performed in 2015, on teeth 8, 9, and 10 is part of the treatment planned following the June 23, 2012, accident and is a covered charge.
Position of the Respondent: Dental crowns provided three years after the date of injury do not qualify as an oral surgical procedure that is the direct result of an accident.
Pertinent Provisions
Article III A(3)(e) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(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.
***
Dental services required as the direct result of an accident.
Discussion
Article III.A.(3)(e) of the Employer Benefit Plan provides benefits for dental services required as the direct result of an accident. The Complainant here suffered serious injuries to his teeth as a result of an accident that occurred while he was repairing his car on June 23, 2012. The Funds’ Medical Director reviewed the Complainant’s dental records and noted that the doctor who initially treated the Complainant indicated that that injured teeth would require root canals and/or crown as a result of the accident. Also the records reflect that the Complainant suffered from diabetes. The Funds’ Medical Directors opined that the treatment plan, which spanned three-years post-accident allowed for healing in the presence of diabetes and improvement of symptoms and that the dental services performed on teeth 8, 9, and 10 in 2015 are related to the accident of June 23, 2012.
Based on the foregoing, the charges associated with the above reference dental work satisfy the criteria necessary to be covered under the Plan. The Complainant sought dental treatment immediately after the June 23, 2012, accident and the treatment he received in 2015 to teeth 8, 9, and 10 was a direct result of the accident. Thus, the employer should be responsible for payment of these services.
Opinion of the Trustees
Pursuant to Article III.A.(3)(e) of the Employer Benefit Plan, the Respondent is required to pay for the dental services performed on teeth 8, 9, and 10 in 2015.