Opinion of Trustees
Resolution of Dispute
Case No. 84-158
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
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 (“UMWA”) 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 hospitalization related to performance of dental procedures under the terms of the Employer Benefit Plan.
On July 18, 1985, the Employee’s twelve year old daughter was admitted to the hospital by the Employee’s family physician to have eight (8) teeth extracted by an oral surgeon in preparation for the placement of orthodontic appliances (braces). The physical exam at the time of admission was entirely within normal limits, except that it revealed spacing problems with the patient’s teeth and multiple caries. There were no complications from the dental surgery, and the Employee’s daughter was discharged from the hospital the following day. The family physician noted on the discharge summary that there was no known reason for the admission other than the child’s anxiety concerning the procedure.
The Employer denied payment because there were no underlying conditions which made the hospitalization necessary and because prior authorization was not obtained.
Is the Employer responsible for payment of the hospital charges incurred during the Employee’s daughter’s hospitalization for dental surgery on July 18, 1985?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the charges resulting from the Employee’s daughter’s hospitalization for a dental procedure.
84-158 – May 9, 1986
Opinion of Trustees Resolution of Dispute Case No. 84-158
Position of the Employer: The Employer is not responsible for providing benefits hospitalization was not necessary due to a pre-existing medical condition and because prior approval was not obtained.
Article III. A. (1) (g) of the 1984 Employer Benefit Plan states in part:
(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures
Benefits are also provided for a beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.
Under Article III. A. (1) (g) of the 1984 Employer Benefit Plan, inpatient hospital benefits are provided when a beneficiary is admitted for the performance of dental procedures only if the hospitalization is necessary due to a pre-existing medical condition and prior approval is received.
In this case, the Employee’s daughter was hospitalized for multiple tooth extractions in preparation for the placement of braces. In a letter to the Employer’s insurance carrier, the oral surgeon described the procedure but made no mention of any underlying medical condition. According to the Employee, the oral surgeon told him that if the family physician would admit his daughter to a hospital, the teeth could all be extracted in one session, rather than extracting one or two at a time over several office visits, According to the physician who admitted her to the hospital, the Employee’s daughter had no medical problems, other than carious teeth and spacing problems, at the time of admission. The physician noted that the patient’s apprehension over the extractions was the only known reason for the hospital admission. This does not constitute an underlying medical condition for which hospitalization would be medically necessary.
Opinion of the Trustees
The Employer is not responsible for the payment of the hospital charges resulting from the Employee’s daughter’s dental procedures on July 18, 1985.