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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 81-683 – March 25, 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 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 treatment of temporomandibular joint dysfunction under the terms of the Employer Benefit Plan.
Background Facts
An orthodontist diagnosed the Employee’s spouse as having temporomandibular joint dysfunction (TMJ) and treated the disorder with a bite splint placed between the patient’s teeth to guide the mandible into the correct position, and installed orthodontic appliances (braces) to correct the malocclusion that results from realigning the jaw. Both procedures were done simultaneously.
The Employer denied payment for the procedures.
Dispute
Is the Employer responsible for payment of the charges incurred by the Employee’s spouse for the treatment of TMJ?
Position of the Parties
Position of the Employee: The Employer is responsible for payment of the charges incurred by the Employee’s spouse for the treatment of TMJ because the treatment was performed to treat a medical problem rather than for cosmetic or aesthetic reasons.
Position of the Employer: The Employer is not responsible for payment of the charges incurred by the Employee’s spouse for the treatment of TMJ because the treatment in question was orthodontic in nature and therefore not a covered expense under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (3)(e) of the Employer Benefit Plan states:
(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 (tongue tie) Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem.
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Article III. A. (11)(a)19 of the Employer Benefit Plan states:
(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 81-88 states:
Control Number: 81-88
Subject: Oral Orthopedics
References:Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19.
Question:
Are benefits provided for treatment of temporomandibular joint dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.
Discussion
Article III. A. (3)(e) and Article III. A. (11)(a) 19 of the Employer Benefit Plan specifically exclude benefits for dental services, except when required as the direct result of an accident. Article III. A. (3)(e) provides for coverage of oral surgical procedures required to treat TMJ, when the services are orthopedic in nature. According to Q&A 81-88, benefits are provided for the treatment of TMJ only when the treatment involves the use of corrective external orthopedic appliances or corrective surgery to specifically reorient the temporomandibular joint.
The bite splint that was used to treat the Employee’s spouse is an external orthopedic repositioning device, designed to guide the bones of the temporomandibular joint into position and therefore meets the requirements of Article III. A. (3)(e) of the Employer Benefit Plan. The orthodontic appliances (braces) were used to reposition the teeth and therefore constitute orthodontic or dental treatment and are not a covered benefit under the Employer Benefit Plan.
In ROD #81-599 (enclosed herein), the Trustees have addressed the question of coverage for the treatment of TMJ. In that case also, the Employee’s child was treated with orthodontic appliances and a bite splint. It was the opinion of the Trustees that the Employer was not responsible for providing benefits for the orthodontic appliances, but was responsible for providing benefits for the bite splint used to specifically reorient the temporomandibular joint.
Opinion of the Trustees
The Employer is not responsible for payment of benefits for that portion of the treatment of the Employee’s spouse’s TMJ that involved the use of orthodontic appliances, but is responsible for the portion of treatment that involved the use of the bite splint.