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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 93-083 – December 1, 1997
Trustees: Michael H. Holland, Michael O. McKown, 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 dental services under the terms of the Employer Benefit Plan.
Background Facts
On May 5, 1996, the Pensioner underwent surgery to have of all of his remaining teeth extracted. Because he had underlying medical conditions, both Medicare and the Employer approved benefits for the hospital admission. Neither Medicare nor the Employer provided benefits for the dental surgery or the dentures he received.
The Pensioner recognizes that the dentures are not a covered service under the Employer Benefit Plan. He believes, however, that benefits should be provided for the dental surgery because it was medically necessary to reduce the risk of systemic infection and other complications related to his chronic medical conditions.
The Employer has denied benefits for the dental surgery charges.
Dispute
Is the Employer required to provide benefits for the Pensioner’s dental surgery?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the dental surgery because it was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the dental surgery because it is not a covered service under the Employer Benefit Plan.
Pertinent Provisions
Article III A. (3) (e) of the 1993 Employer Benefit Plan states:
Article III A. (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. of the 1993 Employer Benefit Plan states:
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) limits benefits for oral surgical procedures to those listed in the 1993 Employer Benefit Plan. Article III A. (11) (a) 19. specifically excludes benefits for dental services.
His physician has noted that the Pensioner had several medical conditions at the time, including severe periodontal disease, seizure disorder and sleep apnea. Because of those underlying medical conditions, Medicare and the Employer Benefit Plan provided benefits for the hospital charges related to this dental surgery.
A Funds’ medical consultant has reviewed the medical documentation submitted with this case and is of the opinion that the surgery was a dental procedure that is not included in the list of covered oral surgeries. Therefore, consistent with the provisions of the Employer Benefit Plan, the Trustees conclude that the Employer is not required to provide benefits for the extraction of the Pensioner’s teeth.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the extraction of the Pensioner’s teeth.