October 25, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 84-070
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 benefits coverage under the Employer Benefit plan for the braces your spouse required for what you have stated to be medically necessary reasons.
Article III A (13)(a) 19 of the Employer Benefit Plan specifically excludes coverage for dental services. In a letter provided in support of this claim and dated December 21, 1984, your spouse’s oral surgeon states, “The orthodontics in [sic] not intended to be of an aesthetic nature, but to relign [sic] the jaws prior to surgery and to maintain a fixed position of the jaws while the surgical sites are healing following surgery.” Orthodontics, according to Dorland’s Medical Dictionary, is the branch of dentistry which deals with the development, prevention and correction of irregularities of the teeth and malocclusion, and with associated facial abnormalities. Orthodontic treatment is therefore considered a dental service and is not a covered benefit under your Employer’s Plan.
In documenting your position in this dispute you note that, in your opinion, the dental services at issue in this dispute were pre-authorized by the Employer’s insurance carrier. A careful review of the January 15, 1985 letter upon which you rely in arriving at this conclusion establishes that the carrier, on behalf of the Employer, pre-authorized benefits coverage only for a period of inpatient hospitalization for dental procedures and not for the dental procedures or services themselves. The pre-authorization to which you refer therefore has no bearing on this dispute.
Since the braces your spouse requires are considered orthodontic appliances used to correct a malocclusion, your Employer is not responsible for providing benefits for this service.
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