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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-670 – January 28, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 the provision of health benefits coverage for orthodontic treatment under the terms of the Employer Benefit Plan.
Background Facts
The Employee is an active miner whose wife is eligible for health benefits under the Employer Benefit Plan. According to information provided by the Employee, his spouse has a functional malocclusion for which orthodontic correction has been recommended. This correction consists of the application of braces. The Employee’s spouse’s attending physician, a Family Practioner, has indicated that she also has symptoms that are consistent with temporomandibular joint dysfunction. The Employer has denied coverage of the orthodontic correction that the Employee’s spouse requires.
Dispute
Is the Employer responsible for payment of the charges incurred by the Employee’s spouse as a result of her orthodontic correction of functional malocclusion?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the charges incurred by the Employee’s spouse for orthodontic care since braces are the patient’s only alternative to correcting a functional malocclusion which she believes is a medical problem.
Position of the Employer: The Employer is not responsible for payment of the charges resulting from the Employee’s spouse’s orthodontic care because orthodontia is not covered under the Plan.
Pertinent Provisions
Article III A (11) (a) 19 of the Employer Benefit Plan states:
(a) In addition to the specific exclusions otherwise contained in this plan, benefits are also not provided for the following:
19. Dental services.
Discussion
Article III A (11) (a) 19. of the Employer Benefit Plan, specifically excludes coverage of dental services. A Funds’ consultant has reviewed the information on file relative to this dispute. He has advised that the orthodontic procedures required by the Employee’s spouse to correct her functional malocclusion are dental services not covered under the Employer Benefit Plan. According to Dorland’s Medical Dictionary, orthodontics is a branch of dentistry which deals with development, prevention and correction of irregularities of the teeth and malocclusion, and with associated facial abnormalities. Therefore, the braces the Employee’s spouse requires are not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing benefits for the orthodontia (braces) the Employee’s spouse requires as a result of her functional malocclusion.