OPINION OF TRUSTEES
ROD Case No: 81-453 – June 8, 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. They hereby render their opinion on the matter.
The Employee’s son was injured in a motorcycle accident on June 17, 1983, in which he sustained a fractured jaw, avulsed teeth and lacerations of his face. He was treated in the emergency room where the avulsed teeth were reimplanted. The Employer has provided coverage for this care, but has denied payment of charges for the subsequent dental care and root canal therapy required as a result of this accident.
Is the Employer responsible for payment of the charges for the dental care and root canal therapy the Employee’s son required as a result of the injuries he sustained in the June 17, 1983 motorcycle accident?
Positions of the Parties
Position of the Employee: The Employee contends that the charges for the 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.
Article III A. (3) (e) and (i) of the Employer’s Benefit Plan states:
III – Benefits
A. Health Benefits
(3) Physicians’ Services and Other Primary Care
(e) Oral Surgery
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
Temporomandibular Joint Dysfunction, only when
medically necessary and related to an oral orthopedic problem
Biopsy of lesions of the oral cavity
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary who receives outpatient emergency medical treatment or medical treatment of an injury as a result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
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.
Q&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
Are the following dental and 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?
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) 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 the treatment for an illness or injury which is otherwise covered.
Although the disputed services were required as a result of the Employee’s son’s accident, they are restorative and were not part of the emergency treatment of his injuries. Furthermore the dental services were not performed in a hospital within 48 hours of the occurrence of the accident, and were not part of the treatment of an otherwise covered condition. Therefore the restorative dental services 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’s son requires as a result of his June 17, 1983 motorcycle accident.