July 28, 1981
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 201
This is in response to your request for an opinion from the Trustees of the United Mine Workers of America Health and Retirement Funds concerning benefits under the Employer’s Benefit Plan for dental services required as a result of an accident.
The information in your file indicates that your spouse required dental treatment on September 24, 1980 as a result of an accident during which her jaw was fractured. She underwent treatment for the repair of teeth damaged in the accident, the removal of infection, and the replacement of a missing tooth which was lost as a result of the fracture. The Employer denied charges of $924.00, stating that “coverage is not provided for dental work of any nature, even if same is required as the result of an accident”.
In establishing the guidelines for determining health benefit coverage for Employees, the Trustees have approved 1978 Contract Q & A #48, which provides that dental and oral surgical procedures are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Since the repair of a fracture of the jaw, including reduction and wiring, is a covered benefit under Article III, Section A (3) (e) of the Employer’s Plan, benefits should be provided for the dental services necessary to treat and repair the fractured jaw. The Trustees are of the opinion that benefits should be provided for the dental services required in this case.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee