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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-672 – July 8, 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 dental services under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s seventeen-year-old dependent son was born without the roots for his two front teeth. Consequently, when his permanent teeth came in those teeth were missing. On April 6, 1992 an oral surgeon performed surgery on the Employee’s son to implant two false teeth. The oral surgeon submitted a bill for the false teeth and related services to the Employer. The Employer paid the benefits due under the dental plan and denied further benefits under the Employer Benefit Plan, stating that the oral surgical procedures performed were not among the limited oral surgical services covered under Article III.A.(3)(e) and dental services are specifically excluded from coverage under Article III.A.(11)(a) 19. of the Plan.
Dispute
Is the Employer required to provide health benefits coverage for the two false teeth and related services provided to the Employee’s son on April 6, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits coverage for the Employee’s son’s false teeth and related services because the two missing front teeth are a kind of birth defect and should be eligible for benefits under the terms of the Employer Benefit Plan.
Position of the Employer: The Employer is not required to provide health benefits coverage for the Employee’s son’s false teeth and related services because the Employer Benefit Plan specifically excludes benefits for dental services with the exception of the limited oral surgical procedures listed in Article III.A.(3)(e).
Pertinent Provisions
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 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.(7)(a) of the Plan states:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
Article III.A.(11)(a) 19. states:
(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 provides benefits for limited oral surgical procedures. Article III.A.(7)(a) 1. of the Plan provides benefits for prosthetic devices that serve as replacements for internal or external body parts, other than dental, when medically necessary and prescribed by a physician. And, Article III.A.(11)(a) 19. of the Employer Benefit Plan specifically excludes coverage for dental services.
The two false teeth and related services provided to the Employee’s son are dental services, which are specifically excluded under Article III.A.(11)(e) 19. of the Employer Benefit Plan. Further, although the Plan provides coverage for prosthetic devices to serve as replacements for internal or external body parts, dental services are specifically excluded under this provision as well. The services provided are not contained in the limited oral surgical procedures listed in Article III.A.(3)(e) of the Plan.
RODs 84-315 and 84-564 (attached) addressed the issue of whether dental services can be considered under the terms of Employer Benefit Plan. In these RODs the Trustees determined that dental and oral surgical procedures were not covered under the Employer Benefit Plan, with the exception of those listed in Article III.A.(3)(e). Inasmuch as dental benefits are provided under Article XX-A of the Coal Wage Agreement, and the Trustees have authority to resolve disputes involving only benefits established by Article XX, the Trustees may not address disputes concerning dental plan benefits.
Since the services provided to the Employee’s son are dental services and are not contained in the limited oral surgical procedures listed in Article III.A.(3)(e), and are not covered orthopedic and prosthetic devices as outlined in Article III.A.(7)(a) 1., the Trustees conclude that these services are not eligible under the Employer Benefit Plan. Further, inasmuch as this case involves the same principles as RODs 84-315 and 84-564, the Trustees similarly may not address any dispute concerning dental plan benefits.
Opinion of the Trustees
The Employer is not required to provide health benefits coverage under the Employer Benefit Plan for the dental services provided the Employee’s son on April 6, 1992.