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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-624 – December 29, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for oral surgery under the terms of the Employer Benefit Plan.
Background Facts
On March 11, 1991, an oral surgeon diagnosed the Employee’s wife with extensive maxillary and mandibular bone loss, which prevented the proper fitting of dentures. The oral surgeon performed surgery on May 31, 1991 to reconstruct her maxilla and mandible with implants, in order to compensate for the bone loss, so that dentures could be properly fitted. The oral surgeon stated that the surgery was also necessary to prevent further complications such as pathological fractures. Another oral surgeon and a dentist submitted letters, dated June 26, 1991 and September 11, 1991, respectively, in support of the oral surgery performed.
The Employer paid $750, the maximum amount payable under the dental plan for services related to reconstruction of the maxilla and mandible, and denied the remaining charges, stating that the procedures are not included on the list of limited oral surgical procedures covered under the Employer Benefit Plan. The Employer also denied charges for dentures because of the five year replacement limitation under the dental plan. Charges for services covered under the dental plan are outside the scope of this dispute.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the expenses incurred in connection with the Employee’s spouse’s oral surgery on May 31, 1991?
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 surgery on May 31, 1991 because three doctors stated that the surgery was medically necessary.
Position of the Employer: The Employer is not required to provide benefits under the Employer Benefit Plan for expenses in connection with the Employee’s spouse’s oral surgery on May 31, 1991 because the surgical procedures are not among those listed as eligible in Article III. A. 3.(e) of the Plan.
Pertinent Provisions
Article III. A. (1)(g) of the Employer Benefit Plan provides:
(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 pre-existing medical condition and prior approval is received from the Plan Administrator.
Article III. A. (3)(e) of the Plan provides:
(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 disfunction, 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. (11)(a)19. provides:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
(19) Dental services.
Discussion
Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Article III. A. (11)(a)19. excludes benefits for dental services. A Funds’ medical consultant has reviewed the information contained in this file, including the letters from the patient’s oral surgeon, the other oral surgeon and the dentist. The consultant has determined that the surgery performed, to compensate for extensive bone loss to the maxilla and mandible so that dentures could be properly fitted, was not among the limited oral surgical procedures covered under the Employer Benefit Plan.
Under Article III. A. (1)(g) of the Plan, benefits are provided for hospitalization for dental procedures only if necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. As an example, pre-existing conditions such as heart disease, hypertension, diabetes or chronic obstructive pulmonary disease (COPD) could put a beneficiary at significant risk of developing complications that could result in further injury, damage or loss if the dental services (covered or non-covered) were performed in a less controlled environment. The Funds’ medical consultant has advised that there is no documentation of a pre-existing medical condition that would have necessitated hospitalization for these dental procedures. Therefore, the requirements for hospitalization under Article III. A. (1)(g) were not met.
Inasmuch as the Employee’s spouse’s oral surgery is not among the limited oral surgical procedures covered under the Employer Benefit Plan and is not medically necessary as part of the treatment for an illness or injury that is otherwise covered under the Plan, the Trustees conclude that the Employer is not required to provide benefits for the Employee’s spouse’s oral surgery.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Employee’s spouse’s oral surgery under the terms of the Employer Benefit Plan.