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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 84-603 – April 7, 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 for oral surgery under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s spouse has polycystic kidney disease with progressive kidney failure and has elected to undergo kidney transplantation as an alternative to renal dialysis treatments. Her physician recommended that she have full mouth extractions of her teeth in order to prevent any potential source of infection subsequent to the transplantation. The Employee’s dentist performed the extractions on an outpatient basis from August 10, 1987 through September 14, 1987 and fabricated and placed complete upper and lower dentures on September 14, 1987.

The Employer has provided dental benefits for the Employee’s dental work under its Dental Plan but denied health benefits coverage because the procedures are not among the oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan and because dental procedures are otherwise covered under the Employer Benefit Plan only when performed in a hospital inpatient setting.

Dispute

Is the Employer responsible for providing health benefits coverage for the Employee’s spouse’s full mouth extraction of teeth?

Positions of the Parties

Position of the Employee: The Employer is responsible for providing health benefits coverage for the Employee’s spouse’s full mouth extraction of teeth because the procedure was medically necessary to prevent any potential source of infection subsequent to her kidney transplantation.
Position of the Employer: The Employer is not responsible for providing health benefits coverage for the Employee’s spouse’s full mouth extraction of teeth because the procedure is not among the oral surgical procedures covered under Article III. A. (3)(e) of the Employer Benefit Plan, and it was performed on an outpatient basis.

Pertinent Provisions

Article III. A. (3)(e) of the 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 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. Full mouth extraction of teeth is not among those procedures covered by the Plan. According to Q&A #81-15 (copy enclosed herein), certain dental and oral surgical procedures, including the extraction of teeth, 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 Employee’s spouse’s oral surgery was performed in a dentist’s office over a two-week period. Inasmuch as the Employee’s spouse’s oral surgery is not among the limited procedures covered under Article III. A. (3)(e) and was not performed in a hospital as required pursuant to Q&A 81-15, benefits are not available under the Employer Benefit Plan.

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 providing health benefits coverage under the Employer Benefit Plan for the Employee’s spouse’s full mouth extraction of teeth.