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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-519 – January 28, 1988
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’s physician and orthodontist referred the Employee to an oral surgeon for evaluation of a congenital facial skeletal deformity. The oral surgeon confirmed the diagnosis of severe maxillary hypoplasia and mandibular hyperplasia with severe dental compensation and recommended maxillary osteotomy advancement, mandibular setback and horizontal osteotomy of the chin area with setback. The proposed oral surgery would require an inpatient stay of approximately three to five days and possible overnight intensive care treatment following the surgery.
The Employer has denied benefits under the Employer Benefit Plan for the proposed maxillary and mandibular osteotomies because such procedures are not among those covered under Article III. A. (3)(e) of the Plan. The Employer has also denied benefits for the related inpatient hospitalization charges because the Employee does not have a preexisting medical condition that would require hospitalization for a dental procedure.
Dispute
Is the Employer responsible for the provision of health benefits for the Employee’s proposed oral surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits for the Employee’s proposed maxillofacial surgery to correct a congenital skeletal deformity.
Position of the Employer: The Employer is not responsible for the provision of health benefits for the Employee s proposed osteotomies because the procedures are not among the oral surgical procedures covered under the Employer Benefit Plan. The Employer is not responsible for the provision of health benefits for the related hospitalization charges because the Employee does not have a preexisting medical condition that meets the requirements of Article III. A. (1)(g) of the Plan.
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
Discussion
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 proposed oral surgery is not among those limited procedures covered under Article III. A. (3)(e) of the Plan.
In addition, according to Q&A 81-15 (copy enclosed herein), certain charges for services for dental and oral surgical procedures are covered under the Employer Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. The Funds’ medical consultant has advised that there is no evidence that the proposed surgery is medically necessary to treat an otherwise covered medical condition.
Article III. A. (I)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization for oral surgical procedures only when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided 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 Funds’ medical consultant has advised that there is no evidence of such a preexisting medical condition.
Because the patient’s proposed oral surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and because there is no evidence that the proposed surgery is medically necessary as part of the treatment for an illness or injury which is otherwise a covered benefit, the professional services fees are not covered under the Employer Benefit Plan. Because there is no evidence of a preexisting medical condition, the patient’s hospitalization does not meet the requirements for coverage under Article III. A. (1)(g).
Opinion of the Trustees
The Employer is not responsible for payment of the charges related to the professional services or the hospitalization for the Employee’s proposed oral surgery under the terms of the Employer Benefit Plan.