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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-315 – January 30, 1987
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 for orthodontic treatment under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has a deep closed bite, multiple missing teeth, and malocclusion, which cause recurrent and persistent pain in her temporomandibular joints and headaches. After approximately three years of conservative treatment with medication which failed to alleviate the pain and headaches, she was referred by her family physician to an oral surgeon for treatment of temporomandibular joint dysfunction. The oral surgeon recommended orthodontic treatment followed by placement of fixed bridges, and referred her to an orthodontist, who placed the Employee’s spouse in orthodontic appliances (braces).
The Employer has denied health benefits coverage for the Employee’s spouse’s orthodontic treatment.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s orthodontic treatment?
Position of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse’s orthodontic treatment because the purpose of the treatment is to correct TMJ dysfunction.
Position of the Employer: The Employer is not responsible for the Employee’s spouse’s orthodontic treatment because it is a dental service and is not a covered benefit under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (11) (a) of the 1984 Employer Benefit Plan states in part:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services.
Article IIIA. (3)(e) of the 1984 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
Fracture of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Q&A 81-15 states:
Subject: Dental and Oral Surgical Services
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (e)
Other: 1981 Contract Q&A #81-16
Question:
Are the following dental and oral surgical procedures covered under the Plan:
a. extraction of teeth?
b. gingevectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?
Answer:
The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Q&A 81-88 states:
Subject: Oral Orthopedics
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.
Discussion
Article III. A. (11)(a)19. of the Employer Benefit Plan, as well as Q&A 81-15, specifically exclude coverage for dental services except in very limited circumstances. Orthodontics is a branch of dentistry which uses mechanical devices (e.g., braces) to prevent and correct irregularly positioned teeth and malocclusion. Orthodontic treatment is therefore a dental service and is not a covered benefit under the Employer Benefit Plan, except in very limited circumstances. Since this case does not involve one of those limited circumstances, the orthodontic treatment received by the Employee’s spouse is not covered under the Employer Benefit Plan.
In addition, Article III. A. (3)(e) of the Employer Benefit Plan provides benefits for limited oral surgical procedures and dental services required as the direct result of an accident. Q&A 81-88 provides benefits for treatment of temporomandibular joint dysfunction when treatment involves the use of corrective external orthopedic appliances or corrective surgery to specifically reorient the temporomandibular joint. The orthodontic treatment recommended for the Employee’s spouse is not oral surgery, nor is it the direct result of an accident. The orthodontic treatment involves the use of orthodontic appliances (braces) and not corrective external orthopedic appliances. Because the Employee’s spouse’s orthodontic treatment is not oral surgery, is not a direct result of an accident and does not require a corrective external orthopedic appliance, it is not covered under the Employer Benefit Plan.
Inasmuch as dental benefits are provided under Article XX-A of the Coal Wage Agreement and the Trustees have authority to resolve disputes involving benefits established by Article XX only, the Trustees may not address disputes concerning dental plan benefits.
Opinion of the Trustees
The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s orthodontic treatment.