OPINION OF TRUSTEES
ROD Case No. 30, August 22, 1979
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee
Pursuant to Article IX of the United Mine Workers of America 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 about the level of health benefits provided to an Employee’s dependent by an Employer and hereby render their opinion of the matter.
Complainant is an active employee of Employer. On July 9, 1978, the Employee’s two dependent children consulted a physician for severe toothaches. The physician diagnosed their problem as severely impacted wisdom teeth and admitted them the same day to a local hospital. The next day, each dependent had four impacted wisdom teeth surgically removed, under general anesthesia by an oral surgeon. They were discharged from the hospital the following day.
The oral surgeon who performed the surgery has stated that, “Due to the severity of the impaction, it was necessary to hospitalize (the) patient(s) for general anesthesia and follow up professional care”.
Question or Dispute
The Employee filed a claim for coverage of the hospitalization charges. The insurance company has denied payment on the claim, The Employer concurs with the insurance company’s decision,
Positions of the Parties
Claimant’s Position: The Employer (insurance company) is responsible for payment of the claim, since hospitalization for dental procedures is covered under the Plan, based on “1978 Contract Q & A #88”.
Employer’s (Insurance Company’s) Position: The Employer (Insurance Company) is not responsible for payment of the claim, since hospitalization for dental procedures are not covered under the Plan, based on Q & A #48.
o Article III, Section A (1) (a) of the Employer Plan provides as follows:
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient (overnight confinement) to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.
o 1978 Contract Question and Answer #48, as approved by the Trustees on June 21, 1978, provides as follows:
Questions:Are the following dental procedures covered under the 1978 Agreement:
a. extraction of teeth?
b. gingivectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty?
d. treatment for abscessed teeth?
e. hospitalization for the above?
Answer: The extraction of teeth, when performed in a hospital, and costs associated with the extraction are covered only when they are part of a treatment for an illness or injury which itself is a covered benefit, Examples of this would be the extraction of teeth during treatment for an auto accident involving extensive facial damage, or during treatment for cancers of the head and neck.
Aside from this provision, none of the above procedures is covered under the 1978 Agreement, since dental services are specifically excluded from the coverage, except for those listed under the Oral Surgery benefit in Section A(3) (e). These include surgical treatment for:
– tumors of the jaw
– fractures of the jaw, including reduction and wiring
– fractures of the facial bones
– frenulectomy, when related to ankyloglossia (tongue tie).
o 1978 Contract Question and Answer #88, approved by the Trustees on April 17, 1979, provides as follows:
Question: Are hospitalization charges related to dental procedures covered under the Plan?
Answer: Yes, when (1) medically necessary and (2) prior authorization has been obtained from the Plan Administrator.
By virtue of Q & A #88, hospitalization for dental treatment, such as the Employee’s children underwent, is covered under the Plan. This Q & A was intended to supersede Q & A #48, and renders part (e) of the question to #48 no longer in effect.
A UMWA District official representing the claimant brought Q & A #88 to the attention of the Employer’s Labor Commissioner, who had been handling the Employee’s grievance on this issue, shortly after the Q & A was approved by the Trustees.
Opinion of the Trustees
The Trustees are of the opinion that the Employer (Insurance Company) is required to cover the hospitalization charges incurred by the Employee’s dependent children. (Prior authorization must be obtained by the Plan Administrator for hospitalization for dental care, effective the date on which Q&A #88 has been published and received by the Plan Administrator.)