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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-332 – April 13, 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 coverage for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee experienced recurrent, severe pain in his lower jaw and was diagnosed by an oral surgeon as having mandibular atrophy. The oral surgeon performed a mandibular jaw augmentation on August 27, 1986 to alleviate the pain, prevent pathological fracture of the mandible and prevent further atrophy of the mandible.
According to the Employer’s insurance carrier, the attending oral surgeon submitted an explanation of the proposed oral surgery on August 14, 1986, requesting prior approval, which was denied under the medical plan. The denial was made by telephone approximately 7-10 days after the request was received.
Dispute
Is the Employer responsible for payment of the charges resulting from the mandibular jaw augmentation performed on the Employee?
Position of the Parties
Position of the Employee: The Employer is responsible for the mandibular jaw augmentation because it meets the requirements of the Employer Benefit Plan. Page 2
Position of the Employer: Mandibular jaw augmentation is not one of the specific oral surgical procedures covered under the Employer Benefit Plan; benefits are therefore not provided.
Pertinent Provisions
Article III A. (3)(e) of the Employer Benefit Plan states:
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 an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Discussion
Under Article III. A. (3)(e) of the Employer Benefit Plan, benefits are provided for only those oral surgical procedures which are specified therein. A Funds’ physician consultant has reviewed the evidence submitted and has advised that the oral surgery performed is not one of the procedures listed in Article III. A. (3)(e) of the Plan.
Opinion of the Trustees
The Employer is not responsible for providing benefits for the Employee’s mandibular jaw augmentation because it is not a covered service under the Employer Benefit Plan.