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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-442 – December 15, 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 dental implants under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner’s spouse had a subperiosteal implant placed on the mandible in 1979. Since that time, she has had ongoing infections coupled with a continuous loss of mandibular bone. The implant is presently exposed and infected and requires removal. The prescribed treatment for the Pensioner’s spouse is to place approximately five implants in her mandible which will provide a base for construction of a permanent fixed mandibular prosthesis.
The Employer paid for the subperiosteal implant in 1979, and the Pensioner contends it should provide benefits for the procedure again under the Employer Benefit Plan or the Employer’s Dental Plan.
The Employer denied coverage under the Employer Benefit Plan for the proposed oral surgery because it is not among the limited oral surgical procedures covered under Article III. A. (3)(e) of the Plan and because the Plan specifically excludes benefits for dental prosthetic devices. The Employer also stated that its Dental Plan specifically excludes benefits for dental implantology and, furthermore, Pensioners and their dependents are ineligible for Dental Plan benefits.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Pensioner’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Complainant: The Employer is responsible for the provision of health benefits coverage for the Pensioner’s spouse’s dental implants because benefits were provided for the same procedure in 1979.
Position of the Respondent: The Employer is not responsible for the provision of benefits under the Employer Benefit Plan for the Pensioner’s spouse’s dental implants because they represent dental services which are not covered under the Employer Benefit Plan. The Employer’s Dental Plan specifically excludes benefits for dental implantology and, furthermore, the Complainant and his dependents are ineligible for Dental Plan benefits.
Pertinent Provisions
Article III. A. (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
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. (7) (a) 1. of the 1984 Employer Benefit Plan states:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
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.
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 procedure covered under the Plan:
a. extraction of teeth?
b. gingivectomy, 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: (I), 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.
Discussion
Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Article III. A. (II) (a) 19. of the Employer Benefit Plan, as well as Q&A 81-15 (copy enclosed herein), specifically excludes coverage for dental services except in very limited circumstances. This case does not involve one of those limited circumstances. In addition, Article III. A. (7)(a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.
Article III. A. (3)(e) of the Employer Benefit Plan provides benefits for certain limited oral surgical procedures; however, since the dental treatment recommended for the Pensioner’s spouse does not involve one of these limited surgical procedures, it does not qualify for coverage under this provision. The fact that an Employer may have paid benefits for a procedure in the past does not make the procedure a covered benefit.
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 under the Employer Benefit Plan for the Pensioner’s spouse’s dental implant treatment.