OPINION OF TRUSTEES
ROD Case No: 88-095 – April 19, 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.
An orthodontist diagnosed the Employee’s dependent son as having a severe Class I, bi-maxillary protrusion malocclusion. After treating him with a vertical chin cup over a 4-year period, the orthodontist referred the Employee’s son to an oral surgeon. The orthodontist and the oral surgeon developed a treatment plan that combined the use of orthodontic appliances (braces) with surgical movement of both the upper and lower jaw bones. After the Employee’s son’s teeth were repositioned, the oral surgeon performed both a maxillary and a mandibular osteotomy on June 16, 1988. The oral surgeon has stated that the surgery was necessary because the Employee’s son’s open bite deformity interfered with his ability to chew his food thereby affecting his diabetic condition.
After reviewing the patient’s history of diabetes, the Employer provided coverage under the Employer Benefit Plan for the hospitalization and anesthesiology charges associated with the oral surgery. The Employer provided benefits for the oral surgery up to the scheduled amount under its Dental Plan. The Employer has denied benefits for the oral surgery under the Employer Benefit Plan.
Is the Employer required to provide health benefits coverage for the Employee’s son’s oral surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits coverage for the Employee’s son’s oral surgery because it was medically necessary.
Position of the Employer: The Employer is not required to provide health benefits coverage for the Employee’s son’s oral surgery because it is not among the covered oral surgical procedures listed under Article III. A. (3)(e) of the Employer Benefit Plan.
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
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
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that the oral surgical procedures performed on June 16, 1988 are not among those procedures covered under Article III. A. (3)(e). The consultant has also advised that the surgery performed in this case is orthodontic in nature in that it was intended to correct a severe malocclusion (open bite).
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 which is otherwise a covered benefit. The medical consultant has advised that the documentation provided does not establish that the Employee’s son’s surgery was medically necessary to treat an otherwise covered medical condition.
Since the Employee’s son’s oral surgery was not a) among the covered oral surgical procedures listed in Article III. A. (3)(e), or b) part of the treatment for an illness or injury which is otherwise a covered benefit, the Employer is not required to provide health benefits for the surgery under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide health benefits coverage for the Employee’s son’s oral surgery.