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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-697 – May 17, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 provisions of health benefits coverage for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner’s spouse complained of malaise, fatigue, recurrent low-grade fevers, nausea and vomiting. She saw an ear, nose and throat specialist, who diagnosed her condition as a chronically infected ranula, a cyst formed under the tongue by the obstruction of a gland duct. The cyst was surgically removed in the hospital. While the Pensioner’s spouse was under general anesthesia for the surgery, her abscessed and decayed lower teeth were extracted by an oral surgeon. The ear, nose and throat specialist stated that these extractions were medically necessary to prevent post-surgical infection and to decrease the possibility of an abscess formation.
The Employer provided benefits for the excision of the ranula under the Employer Benefit Plan but denied benefits for the tooth extractions under the Plan. The Employer also stated that Pensioners and their dependents are ineligible for Dental Plan coverage.
Dispute
Is the Employer required to provide health benefits for the Pensioner’s spouse’s tooth extractions:
Positions of the Parties
Position of the Complaint: The Employer is required to provide health benefits for the Pensioner’s spouse’s tooth extractions because they were ordered by her doctor and were medically necessary.
Position of the Respondent: The Employer is not required to provide health benefits for the Pensioner’s spouse’s tooth extractions because extractions are dental services and are not among the covered oral surgical procedures listed under Article III. A. (3)(e) of the Plan.
Pertinent Provisions
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 a general surgeon:
Tumors of the jaw maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
Frenulectony 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
Under Article III. A. (3)(e) of the Employer Benefit Plan, benefits are provided for certain limited oral surgical procedures if performed by a dental surgeon or general surgeon. In addition, Q&A 81-15 (copy enclosed herein) states that certain dental and oral surgical procedures, including the extraction of teeth, may also be covered under the Employer Benefit Plan if the procedure is performed in a hospital as part of the treatment for an illness or injury that is otherwise a covered benefit.
In this case, the Pensioner’s spouse was hospitalized for surgery to remove a cyst under her tongue. While the Pensioner’s spouse was under general anesthesia, her abscessed and decayed lower teeth were extracted to prevent post-surgical infection and to decrease the possibility of further abscess formation. A Funds’ medical consultant has reviewed this file and advised that the extractions performed in this case were medically necessary as part of the treatment of the patient’s cyst. The Employer provided benefits under the Employer Benefit Plan for the surgery to remove the cyst, a covered benefit. Because the extraction of the pensioner’s spouse’s teeth was part of the treatment of an otherwise covered illness, the Employer is required to provide health benefits for the tooth extractions in this case.
Opinion of the Trustees
The Employer is required to provide health benefits for the Pensioner’s spouse’s tooth extractions.