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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: CA-007 – March 23, 1999
Trustees: A. Frank Dunham, Michael H. Holland, Marty D. Hudson and
Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for oral surgery under the terms of the Coal Act Employer Benefit Plan.
Background Facts
The Pensioner’s spouse is edentulous (has no teeth) and has been fitted for full dentures on three occasions. Each time, she was unable to wear the dentures for more than a few months. Her family physician states that due to her inability to wear her dentures, she is unable to maintain a normal healthy diet and has psychological difficulties.
After the third unsuccessful attempt with dentures, she was referred to an implantologist for possible denture implants. The implantologist performed an alveoloplasty (build-up of the alveolar ridges) to correct the atrophy (shrinking) of the bone which was believed to be the underlying cause of her inability to wear dentures.
The Employer has denied health benefits for the alveoloplasty stating that this oral surgery is not one of the covered oral surgical procedures in the Employer Benefit Plan.
Dispute
Is the Employer required to provide health benefits for the Pensioner’s spouse’s alveoloplasty?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide health benefits for the alveoloplasty because it was medically necessary.
Position of the Employer: The Employer is not required to provide health benefits for the alveoloplasty because it is not one of the covered oral surgical procedures listed in the Employer Benefit Plan.
Pertinent Provisions
Article III A. (3) (e) of the Coal Act 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 Coal Act 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.
Q & A 81-15 states:
Subject: Dental and Oral Surgical Services
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Section A (3) (e)
Other: 1981 Contract Q&A #81 16
Question:
Are the following dental and oral surgical procedures covered under the Plan:
a. extraction of teeth?
b. gingevectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?
Answer:
The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Discussion
Article III A. (3) (e) of the Coal Act Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Article III A. (11) (a) 19. of the Plan excludes benefits for dental services. Q&A 81 15 states that charges for services for certain dental and oral surgical procedures are covered under the Employer Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. No medical evidence has been submitted to substantiate the position that the patient’s oral surgical procedures were performed as part of the treatment of an otherwise covered illness or injury nor were the procedures performed in a hospital.
A Funds’ medical consultant has reviewed the information submitted by the physician and dental surgeon and has determined that the surgical procedures performed, osteoperiostal graft and placement of orthopedic subperiosteal bone stabilizer, are not among the limited procedures covered under Article III A. (3) (e).
Inasmuch as the oral surgical procedures performed on the Pensioner’s spouse are not among the covered oral surgical procedures listed in Article III A. (3) (e) and were not performed as part of the necessary treatment for an illness or injury that is otherwise a covered benefit, the Trustees conclude that the oral surgery is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Pensioner’s spouse’s oral surgery.