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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-080 – April 27, 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 provision of health benefits for treatment provided by an orthodontist for the Employee’s spouse under the terms of the Employer Benefit Plan.
Background Facts
An orthodontist has diagnosed the Employee’s spouse as having a malocclusion with an anterior overbite and intermittent bilateral temporal headaches related to temporomandibular joint syndrome. The orthodontist has characterized the Employee’s spouse’s problem as orthodontic in nature. He initiated an orthodontic treatment plan that includes teeth extraction, the placement of a maxillary splint, and the application of orthodontic braces.
The Employer submitted information provided by the orthodontist, including bilateral temporomandibular joint x-rays, to a dental consultant for review. The Employer denied health benefits coverage for the Employee’s spouse’s treatment stating that the services are orthodontic in nature and that no medical evidence suggests temporomandibular joint dysfunction.
Dispute
Is the Employer required to provide health benefits for the Employee’s spouse’s treatment provided by her orthodontist?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for the Employee’s spouse’s treatment because she is being treated for temporomandibular joint syndrome and such treatment is covered under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide health benefits for the Employee’s spouse’s treatment because no evidence suggests temporomandibular joint dysfunction; rather the treatment is orthondontic in nature and, therefore, is not covered under the Employer Benefit Plan.
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 a general surgeon:
Tummors 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. Among those procedures is treatment for temporomandibular joint dysfunction under certain circumstances. Q&A 81-88 (copy enclosed herein) further indicates that the only two instances in which benefits are provided for treatment of temporomandibular joint dysfunction are when treatment involves (1) the use of corrective external appliances or (2) corrective surgery to specifically reorient the temporomandibular joint.
Although the Employee’s spouse’s treatment included the use of corrective external appliances, a Funds’ medical consultant has reviewed the information submitted in this case and has advised that the Employee’s spouse’s treatment is not covered under Article III. A. (3)(e) because medical documentation does not support a diagnosis of temporomandibular joint dysfunction in this case. The consultant has advised that the proposed treatment is intended to correct an orthodontic problem, malocclusion.
According to Q&A 81-15 (copy enclosed herein) charges for dental and oral surgical procedures 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. The medical consultant has advised that no evidence has been submitted to establish that the Employee’s spouse’s treatment was medically necessary to treat an otherwise covered medical condition.
Since the treatment initiated by the Employee’s spouse’s orthodontist is neither (a) among the covered oral surgical procedures listed in Article III. A. (3)(e), nor (b) part of the treatment for an illness or injury that is otherwise a covered benefit as discussed in Q&A 81-15, such treatment is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Employee’s spouse’s treatment provided by her orthodontist.