OPINION OF TRUSTEES
ROD Case No: 88-067 – February 14, 1989
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 dental services under the terms of the Employer Benefit Plan.
The Employee’s spouse has been fitted with several different sets of dentures since 1977, but continues to experience pain and swelling of the gums. A prosthodontist has determined that the discomfort is caused by a sensitivity to the plastic denture material and has proposed construction of a new set of dentures using chrome cobalt metal bases.
The Employee’s spouse’s physician has stated that the long standing problem with her dentures seems to aggravate her hypertension. In his opinion, correction of the problem with her dentures may alleviate her high blood pressure. The Employer denied coverage for the proposed denture construction.
Is the Employer required to provide health benefits for the Employee’s spouse’s dentures?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for the Employee’s spouse’s dentures under the Employer Benefit Plan because they are medically necessary to alleviate her hypertension.
Position of the Employer: The Employer is not required to provide health benefits under the Employer Benefit Plan for the Employee’s spouse’s dentures because they are dental services and are specifically excluded from coverage.
Article III. A. (7)(a) 1. of the Employer Benefit Plan states:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
These include artificial eyes, noses, hands (or hooks), feet, arms, legs and ostomy bags and supplies.
Article III. A. (11)(a) 19. of The Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services.
Q&A 81-15 states:
Subject: Dental and Oral Surgical Services
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (e)
Other: 1981 Contract Q&A #81-16
Are the following dental and oral surgical procedures covered under the Plan:
a. extraction of teeth?
b. gingivectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibulopasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Article III. A. (11)(a) 19. of the Employer Benefit Plan specifically excludes coverage for dental services. In addition, Article III. A. (7) (a) 1. of the Plan specifically excludes benefits for dental prosthetic devices. Q&A 81-15 states that benefits may be provided for certain dental procedures when performed in the hospital as part of the treatment for an illness or injury which is otherwise covered under the Plan.
The Employee’s spouse suffers from hypertension. Her physician has stated that her condition seems to be aggravated by her sensitivity to plastic denture material and that a new set of dentures constructed from a special material may alleviate the hypertension. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that there is no documentation to support the claim that the patient’s plastic denture material is contributing to her hypertension. The consultant stated that the medical records indicate that the Employee’s spouse is receiving conventional treatment for her hypertension. The consultant further advised that the denture replacement is strictly a dental service and it is not part of the treatment of an otherwise covered illness or injury. The proposed denture replacement, therefore, is not among the limited dental procedures for which benefits may be provided under the Plan, as interpreted in Q&A 81-15.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Employee’s spouse’s dentures.