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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 93-075 – January 23, 1997

Trustees: Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr., and Elliot A. Segal.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for oral surgical correction of the jaws under the terms of the Employer Benefit Plan.

Background Facts

The Employee’s daughter has facial-skeletal deformities resulting from juvenile rheumatoid arthritis. Secondary to this disease, she also has developmental deficiency of both jaws.

In April and August 1994, her physician requested prior approval for the surgical correction of the upper and lower jaws and advancement osteotomy of the anterior lower jaw. The Employer denied benefits, stating that the proposed surgery is not included in the list of covered oral surgical procedures.

Dispute

Is the Employer required to provide benefits for the Employee’s daughter’s oral surgery?

Positions of the Parties

Position of the Employee: The Employer is required to pay for the oral surgery since it is medically necessary to correct a medical condition.

Position of the Employer: The Employer is not required to pay for the oral surgery since it is not one of the covered oral surgery procedures.

Pertinent Provisions

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 a direct result of an accident

Article III A. (11) (a) 19. of the Employer Benefit Plan 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) provides benefits for specifically listed oral surgical procedures. Article III A. (11) (a) 19. excludes benefits for dental services.

A Funds’ medical consultant has reviewed the medical documentation in this case and concludes that there is no evidence presented of the patient having temporomandibular joint dysfunction that would make surgical correction medically necessary. He further concluded that the oral surgical procedures are not within the group of oral surgical benefits of Article III A. (3) (e) of the Employer Benefit Plan. Accordingly, the Employer is not required to provide benefits for the Employer’s daughter’s oral surgery.

Opinion of the Trustees

Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s daughter’s oral surgery.