Opinion of Trustees
Resolution of Dispute
Case No. 88-274
Page 1 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

In Re

Complainant: Respondent: ROD Case No:

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 had complaints of periodic pain, ulcerations and tenderness of the gums, as a result of which she was unable to chew her food properly. An oral surgeon diagnosed her as having an atrophic mandible secondary to degenerative bone disease, which interfered with her ability to wear dentures. The oral surgeon recommended augmentation of the atrophic mandible with hydroxylapatite graft substitute and a skin graft vestibulo-plasty. In a letter dated April 22, 1988 to the Employer’s insurance carrier, the oral surgeon stated that the augmentation could be done as an office procedure, but the skin graft vestibuloplasty, which would be performed two to three months after the augmentation, would require hospitalization and general anesthesia. The augmentation was performed on May 13, 1988, and a portion of the charges was covered under the Employer’s Dental Plan. Prior to the vestibuloplasty, the Employee was notified by letter from the Employer’s insurance carrier that inpatient care was appropriate for the treatment of the Employee’s spouse’s condition, but that approval of hospital admission under the Employer’s pre- certification program is not a guarantee of coverage and does not waive any policy provisions which may affect coverage for the hospitalization. The skin graft vestibuloplasty was performed in the hospital on November 21, 1988.

The Employer has stated that benefits for the Employee’s spouse’s oral surgical procedures may be provided under its Dental Plan, but it denied benefits under the Employer Benefit Plan for the procedures and the related hospitalization charges.

Dispute

Employee
Employer
88-274 – July 25, 1990

Opinion of Trustees Resolution of Dispute Case No. 88-274
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Is the Employer required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgical procedures and the related hospitalization?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgical procedures and the related hospitalization because the surgery was necessary for her health and the Employee received a letter from the Employer’s insurance carrier indicating that the hospitalization would be covered.

Position of the Employer: The Employer is not required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgical procedures because they are not among the oral surgical procedures covered under Article III. A. (3)(e) of the Plan. The Employer is not required to provide benefits for the hospitalization on November 21, 1988 because the oral surgical procedures performed on that date are not covered under Article III. A. (3)(e) and the Employee’s spouse did not have a preexisting medical condition which warranted the hospitalization. Furthermore, the Employee was notified that pre-certification of his spouse’s hospitalization is not a guarantee of coverage and does not waive any policy provisions which may affect coverage for’ the hospitalization.

Pertinent Provisions Article III. A. (i)(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:

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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 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 on the Employee’s spouse on May 13, 1988 and November 21, 1988 are not among the procedures listed under Article III. A. (3)(e).

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 there is no medical documentation that would establish that the procedures performed in this case were medically necessary as a part of the treatment of an illness or injury that is otherwise covered under the Employer Benefit Plan.

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 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 skin graft vestibuloplasty. Although the Employee claims that he received a letter from the Employer’s insurance carrier indicating that the hospitalization would be covered, the letter the Employee received clearly states that the carrier’s determination that inpatient hospitalization is appropriate is not a guarantee of coverage and does not waive any policy provisions which may affect coverage.

Since the Employee’s spouse’s oral surgical procedures are not among 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 for the procedures are not covered under the Employer Benefit Plan. Because the procedures are not covered under Article III. A. (3)(e) and there is no evidence of a preexisting medical condition which necessitated hospitalization, the hospitalization for the oral surgery performed on November 21, 1988 does not meet the requirements for coverage under Article III. A. (1)(g).

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Opinion of the Trustees

The Employer is not required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgical procedures performed on May 13, 1988 and November 21, 1988, nor for the hospitalization pertaining to the oral surgery performed on November 21, 1988.