_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Pensioner
Employer
84-460 – January 11, 1988
Board of Trustees: Joseph 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 anesthesia services for a dental procedure under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner has insulin dependent diabetes mellitus, chronic obstructive lung disease, hypertension, arteriosclerotic cardiovascular disease, stable chronic exertional angina and a history of myocardial infarction. When he required full mouth extraction of his teeth under general anesthesia, the procedure was performed on an inpatient basis in order to minimize the risk of complications related to his medical condition.
The Employer paid the charges related to the inpatient hospitalization and denied those for the anesthesia service. The Pensioner states that the Employer’s insurance carrier gave prior approval for both the hospitalization and the anesthesia service. The carrier’s written notice of prior approval for the hospitalization, however, does not include approval for coverage of anesthesia services.
Dispute
Is the Employer responsible for payment of the anesthesia charges incurred during the Pensioner’s hospitalization for full mouth extraction of teeth?
Positions of the Parties
Position of the Pensioner: The Employer is responsible for payment of the anesthesia charges incurred during the Pensioner’s hospitalization for full mouth extraction of teeth.
Position of the Employer: The Employer is not responsible for payment of the anesthesia charges incurred during the Pensioner’s hospitalization for full mouth extraction of teeth because the
Opinion of Trustees Resolution of Dispute Case No. 84-460 Page 2
anesthesia services were not related to the treatment of a medical condition for which benefits would otherwise be provided under the Employer Benefit Plan.
Pertinent Provisions Article III. A. (1) (g) of the Employer Benefit Plan states:
Oral Surgical/Dental Procedures
Benefits are also provided for a Beneficiary who is admitted to a hospital for 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) (d) of the Employer Benefit Plan states: (3) (d) Anesthesia Services
Benefits are provided for the administration of anesthesia provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, who is not an employee of, nor compensated by, a hospital, laboratory or other institution.
Discussion
In accordance with Article III. A. (1) (g) of the Employer Benefit Plan, the Pensioner’s multiple medical problems qualify as a preexisting medical condition which, according to his physician, necessitated his hospitalization for dental surgery. Recognizing this fact, the Employer authorized payment of the charges resulting from the hospitalization but denied the anesthesia charges related to this surgery.
Q&A 81-16 (copy enclosed herein) provides that physician services, including anesthesia services, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided under the Employer Benefit Plan. The Pensioner’s dental surgery was not related to the treatment of his pre-existing medical problems, even though such problems required that the surgery be performed in a hospital setting. The anesthesia at issue in this dispute was administered as a means to accomplish the dental surgery which is not a covered procedure under the Employer Benefit Plan. Accordingly, the anesthesia services provided in this case do not satisfy the requirements for coverage under the Employer Benefit Plan as established
Opinion of Trustees Resolution of Dispute Case No. 84-460 Page 3
in Q&A 81-16. Therefore, the Employer is not responsible for payment of benefits under the Employer Benefit Plan for the anesthesia services provided to the Pensioner during his hospitalization for dental surgery.
Dental benefits are provided under Article XX-A of the Coal Wage Agreement. The Trustees have authority to resolve only disputes involving benefits established by Article XX. Therefore, the Trustees may not address disputes concerning Dental Plan benefits.
Opinion of the Trustees
The Employer is not responsible for payment of benefits under the Employer Benefit Plan for the anesthesia services provided to the Pensioner during his hospitalization for dental surgery.