Opinion of Trustees
Resolution of Dispute
Case No. 84-342
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-342 – 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 hospitalization related to performance of dental procedures under the terms of the Employer Benefit Plan.
Background Facts
A dental surgeon determined that the Employee’s 18 month-old daughter needed dental surgery. Due to the apprehension, combativeness and anxiety of the child during the dental exam, the dental surgeon recommended that the surgery be performed under general anesthesia in the hospital. The Employee then requested prior approval from the Employer for the hospitalization associated with the dental surgery to be performed on his daughter. The Employer notified the Employee before the scheduled surgery that prior approval had not been granted for the hospitalization. The Employee decided to have the surgery performed in the hospital nonetheless.
The Employer denied payment for the charges related to the hospitalization on the basis that the Employee’s daughter did not have a pre-existing medical condition.
Dispute
Is the Employer responsible for payment of the hospital and associated charges incurred during the Employee’s daughter’s hospitalization on April 3, 1986?
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 dental surgery as the daughter’s infancy causes her to respond to dental procedures the same way as a retarded person would, and thus her infancy constitutes a pre-existing medical condition.
Opinion of Trustees Resolution of Dispute Case No. 84-342
Page 2
Position of the Employer: The Employer is not responsible for payment of the charges resulting from the Employee’s daughter’s hospitalization as the hospitalization was not necessary due to a
pre-existing medical condition.
Pertinent Provisions
Article III. A. (1) (9) 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.
Discussion
Under Article III. A. (1)(g) of the Employer Benefit Plan, benefits are 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.
The Employee asserts that in order to assure proper medical management of his daughter, general anesthesia administered in a hospital was necessary. The dental surgeon states that he recommended the surgery to be performed on the Employee’s daughter under general anesthesia due to the extent of the dental surgery, the age of the child and the situational anxiety of the child. Hospitalization for dental services is covered when a pre-existing medical condition is present which warrants hospitalization to assure the safety of providing dental services. As the Trustees determined in Resolution of Dispute 84-158 (enclosed herein), anxiety over a procedure does not constitute an underlying medical condition for which hospitalization would be medically necessary.
Opinion of the Trustees
The Employer is not responsible for payment of the hospital and associated charges incurred during the Employee’s daughter’s hospitalization for dental services on April 3, 1986.