OPINION OF TRUSTEES
ROD Case No: 81-31, July 27, 1982
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 concerning coverage of dental services under the Employer’s Benefit Plan and hereby render their opinion on the matter.
The Employee’s son was injured in a motorcycle accident on April 21, 1981, in which he sustained a fractured jaw, loss of teeth, fractured teeth, oral lacerations, and intra-abdominal injuries. He was admitted to the hospital where he underwent intra-abdominal surgery as well as two surgical procedures, on April 24, 1981 and on May 4, 1981, for repair of multiple mandibular fractures.
On August 24, 1981, the patient was referred to a dentist for reconstruction of the missing teeth. Coverage of the dental treatment provided on August 24, 1981, has been denied.
Question or Dispute
Is the Employer responsible for payment of the charges for procedures related to the restoration of the patient’s teeth performed on August 24, 1981?
Position of Parties
Employee: The Employee feels that the charges for the restorative dental services are covered because they were the direct result of the motorcycle accident.
Employer: The Plan Administrator bases its denial of coverage for the restoration services on Q&A #48 (subject matter contained in Q&A #81-15).
Article III. A. (3) (e) of the Employer’s Plan which provides as follows:
“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 lesions of the oral cavity
Article III. A. (11) (a) 19 of the Employer’s Plan which specifically excludes dental services from coverage.
Q&A # 81-15
Subject: Dental and Oral Surgical Services
References:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Section A (3) (e)
Other: 1981 Contract Q&A #81-16
Are the following dental and oral surgical procedures covered under the Plan:
a. extraction of teeth?
b. gingevectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, destibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Under Article III. A. (3) (e) of the Employer’s Benefit Plan, dental services are specifically excluded as a covered service. Under Q&A #81-15, certain dental and oral surgical procedures are covered, but only when performed in a hospital as part of treatment for an illness or injury which is a covered benefit.
The specific services in dispute in this case are those related to restorative dental procedures provided on August 24, 1981, approximately four months after the Employee’s son’s accident. Because these services were not part of the emergency treatment of the traumatic injuries, and are not an otherwise covered benefit, they are excluded from coverage by the Employer’s Benefit Plan.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is not responsible for payment for the restorative dental services provided on August 24, 1981, to the Employee’s dependent son.