Opinion of Trustees Resolution of Dispute Case No. 84-085
October 25, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees ROD: 84-085
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 hospital charges resulting from your son’s dental extractions.
According to the provisions of Article III A. (1)(g) of the Employer Benefit Plan, benefits are provided for hospitalization for dental procedures only if the hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. A Funds’ medical consultant has reviewed the information on file regarding this dispute. It was his opinion that the clinical evidence you submitted in support of your claim establishes that your son’s dental extractions were done in a hospital setting under general anesthesia only because of his age and his failure to cooperate in the dentist’s office. Accordingly, he has noted that you have not provided medical information sufficient to establish that your son’s hospitalization for dental extractions was necessary because of a pre-existing medical condition. Furthermore, prior authorization of this hospitalization had not been granted by the Plan Administrator.
Because there is no evidence that your son had a pre-existing medical condition, and because prior approval was not obtained from the Plan Administrator, your Employer is not responsible for payment of the charges resulting from your son’s hospitalization for dental care.
Donald E. Pierce, Jr., Trustee
Sincerely, ________________________________ Joseph P. Connors, Sr., Chairman ________________________________ Paul R. Dean, Trustee ________________________________ William B. Jordan, Trustee ________________________________ William Miller, Trustee ________________________________