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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-436 – November 20, 1991
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 inpatient hospitalization for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Pensioner’s spouse was seen by an oral surgeon because of difficulty In chewing and functioning with a mandibular (lower jaw) denture. The surgeon diagnosed severe mandibular atrophy and undertook a two-stage correction. In the first stage, the mandible was reconstructed with synthetic bone graft substitute in the oral surgeon’s office in February 1990. The charges for this procedure are not in dispute. On April 24, 1990, the patient was hospitalized for the second-stage procedure which consisted of a mandibular vestibuloplasty (soft tissue connection) with skin grafting and lowering of the floor of the mouth. The oral surgeon’s charges for this second procedure are not in dispute. However, the Pensioner contends that the hospitalization costs should be covered under the Employer Benefit Plan.
The Employer has denied benefits for the hospitalization costs incurred in connection with the second-stage surgical procedures.
Dispute
Is the Employer required to provide benefits for the Pensioner’s spouse’s hospitalization for oral surgery performed on April 24, 1990?
Positions of the Parties
Position of the Pensioner: Thee Employer is required to provide benefits for the Pensioner’s spouse’s hospitalization for oral surgery because it was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the hospitalization for oral surgery because the surgery performed is not one of the covered oral surgical procedures listed under Article III. A. (3)(e) 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. (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 preexisting medical condition and prior approval has been received from the Plan Administrator. For example, preexisting conditions such as heart disease, hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) may put a beneficiary at significant risk of developing complications that could result in additional injury, damage or loss if the non-covered dental services were performed in a less controlled environment. A Funds’ medical consultant has reviewed this case and advised that the mandibular vestibuloplasty with skin grafting is not among the covered oral surgical procedures listed under Article III. A. (3)(e). The Funds’ medical consultant has also advised that there is no evidence of a pre-existing medical condition that would have required hospitalization for the performance of the procedures in this case.
Inasmuch as the oral surgical procedures performed on April 24, 1990 are not among the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a pre-existing medical condition which necessitated hospitalization for the surgery, the Pensioner’s spouse’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 benefits under the Employer Benefit Plan for the Pensioner’s spouse’s hospitalization for oral surgery.