December 21, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-370
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 your Request for Resolution of Dispute concerning coverage under the Employer’s Benefit Plan for your daughter’s hospitalization for oral surgery.
Article III. A. (3)(e) of your Employer’s Benefit Plan specifically excludes benefits for dental services, except for the following limited oral surgical procedures, when performed by a dental surgeon or oral 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. (1)(g) of your Employer’s Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III A. (3)(e). Benefits are also provided under this provision when hospitalization for a dental procedure is necessary due to a beneficiary’s pre-existing medical condition, and when prior approval has been received from the Plan Administrator.
A Funds medical consultant has advised us that your daughter’s oral surgery is not one of the procedures listed in Article III. A. (3)(e), and that she did not have a pre-existing medical condition which would satisfy the requirements of Article III. A. (1)(g). In addition, prior approval of this hospitalization was not obtained from your Plan Administrator. Therefore, your Employer is not responsible for payment of charges related to your daughter’s hospitalization for oral surgery in this instance.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee