Opinion of Trustees
Resolution of Dispute
Case No. 84-594
Page 1 ___________________________________________________________________________

OPINION OF TRUSTEES ___________________________________________________________________________

Complainant: Respondent: ROD Case No:

In Re

Employee
Employer
84-594 – March 16, 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 dependent son was seen by a pedodontist (pediatric dentist) when he was two and a half years old for treatment of eight teeth with exposed nerves and dental caries. The dentist stated that the child complained of pain and his food intake had decreased due to his impaired ability to chew certain foods. Because of the child’s young age and unmanageable behavior, the dental treatment, which consisted of root canals and crowns, was performed under general anesthesia in the hospital. The dentist stated that he would not have subjected the child to the risks of general anesthesia unless it was medically necessary.

The Employer paid the anesthesiologist and the dentist for their services up to the scheduled amounts under the Dental Plan. It denied payment of the anesthesia charges under the Employer Benefit Plan because the services cannot be considered as part of the treatment of an otherwise covered medical condition. The Employer denied the hospital charges because prior approval had not been obtained and there was no evidence of a preexisting medical condition which would satisfy the requirements of Article III. A. (1)(g) of the Plan.

Dispute

Is the Employer responsible for the provision of health benefits under the Employer Benefit Plan for the anesthesia and hospitalization charges associated the Employee’s son’s dental treatment?

Positions of the Parties

Opinion of Trustees Resolution of Dispute Case No. 84-594
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Position of the Employee: The Employer is responsible for the provision of health benefits under the Employer Benefit Plan for the anesthesia and hospitalization charges associated with the Employee’s son’s dental treatment.

Position of the Employer: The Employer is not responsible for the provision of health benefits under the Employer Benefit Plan for the anesthesia and hospitalization charges because there was no preexisting medical condition which necessitated hospitalization for the dental procedures and because prior approval was not obtained.

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

Opinion of Trustees Resolution of Dispute Case No. 84-594
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Discussion

Under Article III. A. (3)(e) of the Employer Benefit Plan, benefits for dental services are excluded except when required as the direct result of an accident. Q&A 81-16 (copy enclosed herein) provides that physician services, including anesthesia services, in connection with hospitalization for a non-covered dental procedure are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided.

The Employee’s son’s dental treatment (root canals and crown work) was not required as the direct result of an accident and, therefore, is rot covered under Article III. A. (3)(e) of the Plan. The dentist states that the dental treatment was performed on the Employee’s son under general anesthesia in a hospital due to the complexity of the treatment, the age of the child and his unmanageable behavior. A Funds’ medical consultant has advised that the Employee’s son’s dental treatment was not related to the treatment of an otherwise covered medical condition. The anesthesia at issue here was administered as a means to accomplish the non-covered dental treatment. Accordingly, the anesthesia services provided in this case do not satisfy the requirements for coverage under the Employer Benefit Plan as established in Q&A 81-16. The Employer is therefore not responsible for providing health benefits under the Employer Benefit Plan for the anesthesia services associated with the Employee’s son’s dental treatment.

Article III. A. (1)(g) of the Plan provides benefits for 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 when hospitalization for a dental procedure is necessary due to a Beneficiary’s preexisting medical condition and prior approval has been received from the Plan Administrator. The Funds’ medical consultant found no evidence of a preexisting medical condition that would satisfy the requirements for hospitalization under Article III. A. (1)(g). There is no evidence of any attempt in this case to obtain prior approval for the hospitalization as required in Article III. A. (1)(g). Therefore, the Employer is not responsible for providing health benefits under the Employer Benefit Plan for the Employee’s son’s hospitalization for dental treatment.

Opinion of the Trustees

The Employer is not responsible for providing health benefits under the Employer Benefit Plan for the anesthesia and hospitalization charges associated with the Employee’s son’s dental treatment.