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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-227 – February 15, 1990
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 coverage for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse went to a dental surgeon on September 21, 1988 with continuing mouth pain, particularly upon chewing. The dental surgeon determined that she suffered from degeneration of the mandibular alveolus (the bony cavities of the mandible in which the roots of the teeth are attached) resulting in compression and exposure of the inferior alveolar nerves on both sides of her mouth. In a letter dated June 12, 1989, he stated that because of these problems, the Employee’s spouse was obliged to maintain a soft, high-carbohydrate diet which caused her to gain weight, and which, he felt, predisposed her to other medical problems such as hypertension and diabetes. On January 25, 1989, the dental surgeon performed a full mandibular ridge augumentation and placed a mandibular staple bone plate.
The Employer provided benefits for the oral surgery up to the scheduled amount under the Dental Plan. The Employer denied benefits for the oral surgery and related hospitalization under the Employer Benefit Plan.
Dispute
Is the Employer required to provide health benefits coverage for the Employee’s spouse’s oral surgery and related hospitalization under the Employer Benefit Plan?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits coverage for the Employee’s spouse’s oral surgery under the Employer Benefit Plan because it is a medical problem, rather than a dental problem, and such treatment is covered under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide health benefits coverage for the Employee’s spouse s oral surgery under the Employer Benefit Plan because it is not one of the covered oral surgical procedures under Article III. A. (3)(e). The Employer is not required to provide health benefits coverage for the related hospitalization charges because prior approval was not sought from the Plan Administrator and a preexisting medical condition has not been documented, as required under Article III. A. (1)(g) of the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (1)(g) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3) (e) provided hospitalizatIon is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.
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 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
Discussion
Article III. A. (3)(e) of the Employer Benefit Plan states that benefits are not provided for dental services, and it specifies the limited oral surgical procedures for which benefits are provided. A Funds’ medical consultant has reviewed the information submitted in this case and advised that the oral surgical procedures performed in this case are not among the procedures listed under Article III. A. (3)(e). According to Q&A 81-15 (copy enclosed herein), other dental and oral surgical procedures may be 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 medical consultant has advised that the documentation provided does not establish that the Employee’s spouse’s surgery was medically necessary as part of the treatment of an otherwise covered medical condition.
Article III. A. (1)(g) of the Employer Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in Article III. A. (3)(e). Inpatient hospital benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and when prior approval has been received from the Plan Administrator. The medical consultant has advised that there is no evidence of a preexisting medical condition that would have necessitated hospitalization for the Employee’s spouse’s oral surgery.
Since the patient’s oral surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) nor part of the treatment for an illness or injury which is otherwise a covered benefit, the professional services fees are not covered. Because the surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a preexisting medical condition, the patient’s hospitalization does not meet the requirements for coverage under Article III. A. (1)(g).
Opinion of the Trustees
The Employer is not required to provide health benefits coverage for the Employee’s spouse’s oral surgery and hospitalization.