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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-764 – December 15, 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 health benefits coverage for oral surgical procedures under the terms of the Employer Benefit Plan.
Background Facts
On August 18, 1992, the Employee’s daughter had her four wisdom teeth removed by an oral surgeon in his office while she was under intravenous sedation. The oral surgeon stated that the teeth were impacted in such positions that, when they came in, they would not be in a position that would benefit the patient. The oral surgeon additionally stated that these teeth would eventually develop cysts and cause infection and pain. He stated that he chose to removed the four teeth before any problems developed.
The Employer paid benefits under its dental plan, and denied benefits under the medical plan. The Employee states that because the four teeth were considered full boney impactions, benefits should be available under the medical portion of the Plan.
Dispute
Is the Employer required to provide medical benefits for the removal of the Employee’s daughter’s four impacted wisdom teeth on August 18, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide medical plan benefits for the removal of his daughter’s four wisdom teeth because the teeth were considered to be full boney impactions and therefore, eligible for benefits under the medical portion of the Plan.
Position of the Employer: The Employer is not required to provide medical benefits for the removal of the Employee’s daughter’s four wisdom teeth because they are not among the limited oral surgical procedures provided for in Article III.A.(3)(e).
Pertinent Provisions
(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 a direct result of an accident
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 a limited number of covered oral surgical procedures. Article III. A. (11)(a) 19. excludes coverage for dental services.
The oral surgeon stated that the Employee’s daughter’s wisdom teeth were such in a position that they would never benefit her, and that the removal was performed to avoid potential future infection and pain. The four wisdom teeth (numbers 1, 16, 17, and 32) were removed in the oral surgeon’s office under intravenous sedation.
The Employer provided benefits for the procedures under the dental portion of its Plan. The Employee states that because the four wisdom teeth were considered full boney impactions, that they should be considered under the medical portion of the Employer’s benefit plan.
In ROD 88-697 (copy attached) a Funds’ medical consultant concluded that the extraction of wisdom teeth is not among the limited covered oral surgical procedures listed in Article III. A. (3)(e) of Plan, and are specifically excluded under Article III.A.(11)(a) 19. of the Plan. Because the services rendered to the Employee’s daughter do not fall within the Employer Benefit Plan’s limited coverage for oral surgical procedures, the Trustees conclude that the Employer is not required to provide benefits for the removal of the Employee’s daughter’s wisdom teeth on August 18, 1992.
Further, although the Employee has raised the issue of dental plan coverage for the services provided to his daughter, this is not an issue that may be addressed in a Resolution of Dispute. The opinion of the Trustees is concerned solely with whether the services in question fall within the limits of oral surgical procedures covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery on August 18, 1992.