April 7, 1986
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-664
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 of your sons s dental care under the terms of your Employer Benefit Plan.
You have asked whether or not dental services provided in connection with an underlying medical problem are covered under Article XX of the 1981 Coal Wage Agreement.
According to Article III A (3)(e) for The’ Plan, 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:
o Tumors of the jaw (maxilla and mandible>
o Fractures of the jaw, including reduction and wiring
o Fractures of the facial bones
o Frenulectomy when related only to ankyloglossia (tongue tie)
o Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
o Biopsy of lesions of the oral cavity
In addition, clarification of the above coverage for oral surgery is provided by the Trustees in Q&A #81-82 which states:
Subject: Inpatient Hospital and Physician Coverage Associated with Provisions of Non-Covered Benefits
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (g)
Question:
A beneficiary acquires a condition, the treatment for which is not a covered benefit (e.g., dental treatment or oral surgery). Hospitalization is required for this treatment only because of a pre-existing condition (such as heart disease), the treatment for which is a covered benefit.
1. Are benefits provided for the hospitalization costs?
2. Are benefits provided for the physician’s fees associated with care for the prior condition?
3. In the case of the non-covered services, i.e., dental treatment, are benefits provided for the charges associated with it?
Answer:
1. Yes, if prior approval is obtained from the Plan Administrator.
2. Yes. Benefits are provided for charges associated only with the prior condition, which is a covered benefit.
3. No. (Dental services are not a covered benefit.)
A Funds’ consultant has reviewed the information on file and has found that none of the oral surgical procedures performed on your son is among those listed above. While your son’s hospitalization was necessary to reduce the risk of complication due to the preexisting heart problem, the dental services were provided for dental caries and that treatment is not a covered benefit. Therefore, your Employer is not responsible for payment under the medical plan for the dental charges incurred after your dental benefits ceased.
You have submitted certain disputed bills for dental services rendered before your dental coverage ceased. It is not within the Trustees’ authority to resolve disputes concerning dental plan coverage under Article XX-A of the 1981 Coal Wage Agreement, thus dental services received in 1983 have not been addressed.
Sincerely,
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Joseph P. Connors, Sr., Chairman
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Paul R. Dean, Trustee
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William B. Jordan, Trustee
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William Miller, Trustee
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Donald E. Pierce, Jr., Trustee