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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-086 – February 24, 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 dental services under the terms of the Employer Benefit Plan.
Background Facts
In 1978 the Employee’s three-year old daughter was injured in an automobile accident. The child’s five upper front teeth were knocked out as a result of the accident. An orthodontist’s evaluation three days after the accident indicated that the extent of the damage and the resultant problems could not be determined until her permanent teeth came in. Re-evaluation was recommended when her permanent teeth came in at age twelve. In 1985, when the Employee’s daughter was almost 12 years old, she was re-evaluated. The orthodontist identified several dental problems which, in his opinion, resulted from the automobile accident. They included deformed and discolored upper front teeth as well as a missing tooth. Orthodontia and subsequent crown and bridge work were recommended; the orthodontic treatment was begun. The Employer denied payment for orthodontic services on the grounds that dental services are not covered by the Employer Benefit Plan.
Question or Dispute
Is the Employer responsible for providing benefits for dental services required as the direct result of an accident?
Position of the Parties
Position of the Employee: The Employer is responsible for providing benefits for dental care the Employee’s daughter needs as a result of an automobile accident.
Position of the Employer: The Employer is not responsible for providing benefits for dental services.
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 oral orthopedic problem.
Biopsy of the oral cavity
Dental services required as a direct result of an
accident
Discussion
Under Article III. A. (3) (e) of the 1984 Employer Benefit Plan, benefits are payable for dental services required as a direct result of an accident. The accidental injury in this case occurred prior to the October 1, 1984 effective date of the Plan provision under which dental services required as a result of an accident are covered. However, the services in question were performed after the coverage effective date. It was necessary to defer the dental and orthodontic work on the Employee’s daughter until her permanent teeth came in and the services were performed as soon as it was medically feasible to provide them.
Two prior ROD opinions are relevant to this case. In ROD 57, the Employee sustained an eye injury in August 1977 and had the eye removed in June 1978. In ROD 316, the Employee injured his leg in December 1975 and had the leg removed in November 1980. In each case, the accidental injury occurred prior to March 27, 1978, the effective date of the Employer Benefit Plan’s provision for dismemberment benefits. The opinion of the Trustees in each case stated that the Employer was responsible for paying dismemberment benefits because the loss occurred after the effective date of the benefit. In addition, the Plan does not exclude benefits for services required to treat pre-existing conditions. Benefits are therefore payable under Article Ill. A. (3) (e) for dental services required as the direct result of an accident, provided that, in those cases where
the accident occurred prior to October 1, 1984, the services were provided as soon as it was medically feasible to do so.
Opinion of the Trustees
The Employer is responsible for providing benefits for the Employee’s daughter’s dental services required as the direct result of an accident.