_____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-288 – August 3, 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 benefits for oral surgery and related hospital charges under the terms of the Employer Benefit Plan.
Background Facts
On December 15, 1989, the Employee’s spouse underwent surgery to remove four impacted, infected wisdom teeth and a lesion on the right mandible. According to the oral surgeon, he performed the surgery in the outpatient department of a hospital because the Employee’s spouse has a grade I/VI heart murmur, and continuous intravenous IV antibiotic medications were required prior to, during and after the surgery to protect her from possible infection. The Employer has denied coverage for the Employee’s spouse’s oral surgery and the related outpatient hospital charges under the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the Employee’s spouse’s oral surgery and the related outpatient hospital charges?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits because the Employee’s spouse’s oral surgery and related hospitalization were medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s oral surgery because the surgery is not among the covered procedures listed in Article III. A. (3)(e) of the Employer Benefit Plan and there is no evidence that the surgery was performed as part of an otherwise covered treatment. The Employer is not required to provide benefits for the outpatient hospital charges in question because the
Opinion of Trustees Resolution of Dispute Case No. 88-288 Page 2
Employee’s spouse’s heart murmur is not a pre-existing medical condition that would necessitate that the surgery be performed in a hospital setting and prior approval was not received from the Plan Administrator, as required by the Employer Benefit Plan.
Pertinent Provisions Article III. A. (1)(g) of the Employer Benefit Plan states:
(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: (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
Opinion of Trustees Resolution of Dispute Case No. 88-288 Page 3
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 that 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). Benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s pre-existing medical condition and prior approval has been received from the Plan Administrator. According to the oral surgeon, the surgery in this case was performed in an outpatient hospital setting because of the Employee’s spouse’s grade I/VI heart murmur. The medical consultant has advised that the presence of a grade I/VI heart murmur would not, by itself, require that the patient be hospitalized for the procedures performed in this case. The consultant has advised that, on the basis of the information provided, the Employee’s spouse’s hospitalization was not required due to a pre-existing medical condition. In addition, prior approval was not received from the Plan Administrator.
Inasmuch as the oral surgery performed in this case 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 that is otherwise a covered benefit, the professional services fees are not covered. Since the surgery is not one of the covered oral surgical procedures listed in Article III. A. (3) (e), there is no evidence of a pre-existing medical condition that would require hospitalization, and prior approval was not received from the Plan Administrator, 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 for the Employee’s spouse’s oral surgery and the related outpatient hospital charges.