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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-418 – December 2, 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 oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse saw a dental surgeon for marked atrophy of the maxilla and mandible. He performed maxillary ridge augmentation and inserted mandibular endosseous implants to halt the atrophy and to buttress the remaining bone. According to the dental surgeon, such procedures are usually performed in an outpatient facility. However, in this case the Employee’s spouse’s physician recommended that the oral surgery be performed in a hospital because of her history of heart disease with arrhythmias. The Employee’s spouse says that she made several attempts to obtain prior approval but was unable to contact the Plan Administrator.
The Employer’s records do not indicate any contact from either the Employee’s spouse or her dental surgeon until September 1986, three months after the June 1986 hospitalization. The Employer denied payment for the inpatient charges related to the oral surgical procedures because prior approval was not requested from the Plan Administrator. The Employer also states that it has administered the dental benefits in accordance with Article XX-A of the Dental Plan and is not responsible for any additional reimbursement for these charges.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the professional fees and the hospitalization charges for the Employee’s spouse’s oral surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits under the Employer Benefit Plan for the professional fees and the hospitalization charges for the Employee’s spouse’s oral surgery.
Position of the Employer: The Employer is not responsible for the provision of health benefits under the Employer Benefit Plan for the professional fees for the Employee’s spouse’s oral surgery because benefits were administered in accordance with the provisions of the Dental Plan. The Employer is not responsible for the provision of health benefits for the related hospitalization charges because prior approval was not obtained from the Plan Administrator.
Pertinent Provisions
Article III. A. (1)(g) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3) (e) provided hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.
Article III. A. (3)(e) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care
(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
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
Article III. A. (11)(a) 19. of the Employer Benefit Plan states:
(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.
Discussion
Article III. A. (11)(a) 19. of the Employer Benefit Plan specifically excludes coverage for dental services except in very limited circumstances.
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. A Funds medical consultant has reviewed the information submitted by the oral surgeon and has advised that the dental surgery performed on the Employee’s spouse is not among the limited procedures covered by Article III. A. (3)(e) of the Plan. Because the Employee’s spouse’s dental surgery is not one of the oral surgical procedures specified in Article III. A. (3)(e) of the Employer Benefit Plan, it is not covered under the Employer Benefit Plan.
Article III. A. (1)(g) of the Employer Benefit Plan provides benefits for a medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided under Article III. A. (1)(g) of the Plan when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and when prior approval has been received from the Plan Administrator.
The Employer has established procedures for the referral of a Beneficiary’s request for prior approval in the event that a particular individual is unavailable. While the Employee’s spouse claims that she made numerous attempts to contact two benefits counselors to request prior approval, she is unable to provide any documentation or other evidence of such attempts. In addition, neither the Employer nor the insurance carrier have any record of contacts from either the Employee’s spouse or the oral surgeon until after the surgery was performed. Inasmuch as the Employee’s spouse’s oral surgery is not among the procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan, and prior approval was not received from the Plan Administrator, the patient’s hospitalization does not meet the requirements for coverage under Article III. A. (1)(g) of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing health benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgery or for payment of the related hospitalization charges.