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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-086 – 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 oral surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s stepdaughter had impacted teeth and retrognathic maxilla, a deformity of the facial skeleton. The dental surgeon requested a dental Predetermination of Benefits (POB) from the Employee’s dental insurance carrier. On, April 12, 1996, the carrier provided the POB itemizing the benefits that could be provided. The POB also stated it was not a guarantee of payment and cited “age limitations” as one of several conditions that could reduce benefits. The POB made no mention of any benefits/limitations for the inpatient hospital stay.
The patient had the impacted teeth surgically removed in May 1996 and the appropriate dental benefits were provided. On November 22, 1996, she underwent surgery to correct the skeletal deformity and remained in the hospital for two days. Benefits for this oral surgery were denied because she had reached nineteen years of age in August and therefore was no longer eligible for dental benefits, The dental surgeon states that her condition resulted in poor mastication which, in turn, caused her to have underlying medical conditions. There has been no recurrence of these underlying medical conditions since completion of her surgery.
The Employee’s request that oral surgery benefits be provided under the medical portion of the Employer Benefit Plan has been denied by the Employer.
Dispute
Is the Employer required to provide oral surgery benefits for the Employee’s stepdaughter’s oral surgery?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the stepdaughter’s oral surgery because it was medically necessary to resolve her underlying medical conditions.
Position of the Employer: The Employer is not required to provide benefits for the stepdaughter’s oral surgery because it is not one of the oral surgical procedures covered under the Employer Benefit Plan.
Pertinent Provisions
Article III A. (1) (g) of the 1993 Employer Benefit Plan states:
(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 subsection (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 1993 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 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:
(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. (1) (g) of the 1993 Employer Benefit Plan provides hospital benefits for covered oral surgery and for noncovered oral surgery admissions when pre-existing medical conditions make hospitalization medically necessary. Article III A.(3) (e) limits covered oral surgery to those procedures that are specifically listed. Article III A. (11) (a) 19. excludes benefits for dental services.
A Funds’ medical consultant has reviewed the documentation and has concluded that the Employee’s stepdaughter’s surgery is not one of the oral surgical procedures covered by Article III A.(3) (e), nor is it a treatment for an illness or injury that is otherwise a covered benefit. He further notes that there is no medical documentation that the patient had a pre-existing medical condition that would require hospitalization to perform these procedures. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the stepdaughter’s oral surgery.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide medical benefits for the Employee’s stepdaughter’s oral surgery or for her inpatient hospitalization.