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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-385-March 26, 1984
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.
Background Facts
The Employee was injured in a motorcycle accident on October 1, 1983, in which he sustained fractured ribs, chipped teeth and lacerations of his face and leg. He was admitted to the hospital following emergency room evaluation and treatment. and was discharged on October 5, 1983. The Employer has provided coverage for this care, but has denied authorization for payment of charges for dental treatment to repair the Employee’s chipped teeth.
Dispute
Is the Employer responsible for payment of charges for the restoration of the Employee’s teeth required as a result of the injuries sustained in the October 1, 1983 motorcycle accident?
Positions of Parties
Position of the Employee: The Employee’s representative contends that the charges for the restorative dental services should be covered because they were the direct result of the motorcycle accident.
Position of the Employer: The Plan Administrator’s denial of coverage for restorative dental services is correct since the Employer’s Benefit Plan Specifically excludes coverage of dental services.
Pertinent Provisions
Article III A. (3) (e) of the Employer’s Benefit Plan states:
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 Benefit Plan provides:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services.
V&A #81-15 provides:
Subject: Dental and Oral Surgical Services
Reference:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Section A (3) (e)
Other: 1981 Contract Q&A #81-16
Question:
Are the following dental ana oral surgical procedures covered under the Plan:
a. extraction of teeth?
b. gingevectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?
Answer:
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 fracture jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Discussion
Under Article III A. (3) (e) and Article III A. (11) (a) 19. 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. 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 Employer is not responsible for payment for the restorative dental services the Employee requires as a result of his October 1, 1983 motorcycle accident.