November 25, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of the Trustees
ROD No: 84-093
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 daughter’s dental care. You have asked if the charges resulting from this care are allowable under either the medical or dental plans.
Under the exemption granted by The Department of Labor, the Trustees may resolve disputes arising under Article XX of the National Bituminous Coal Wage Agreement of 1984 (“Agreement”) which covers the Employer Benefit Plan for medical care. Dental coverage is provided under Article XX-A of the Agreement and is outside the Trustees’ authority to address; therefore, this opinion is provided in response to questions concerning the medical plan only.
According to Article III A (1)(g) of the Employer Benefit Plan, hospitalization for a dental procedure can be considered a covered benefit only when hospitalization is necessary due to a preexisting medical condition and prior approval has been received from your Plan Administrator. Hospitalization for a dental procedure would not qualify under this provision based solely on the difficulty, complexity or extent of the dental service in and of itself; rather it must be necessary to assure proper medical management, control or treatment of the patient in light of the underlying medical condition.
A Funds’ consultant has reviewed the information on file regarding your dispute. The medical information supplied does not establish that your daughter’s hospitalization for dental care was required by a preexisting medical condition in that her history of headaches would not preclude the safe and/or effective extraction of her four impacted wisdom teeth in a setting other than the hospital.
In addition, Article III A (3)(e) of your Employer Benefit Plan excludes dental services from coverage, thus the dental charges relative to your daughter’s hospital care on February 19, 1985 are not covered benefits under the plan.
Because your daughter’s hospitalization was not due to a preexisting medical condition, and because prior approval was not obtained from your Plan Administrator, your Employer is not responsible for payment of charges for your daughter’s hospitalization for dental care, including dental and anesthesia services.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
William Miller, Trustee
Donald E. Pierce, Jr., Trustee