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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: CA-069 – June 30, 2003
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 under the terms of the Coal Industry Retiree Benefit Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
Background Facts
The Complainant’s spouse has been diagnosed with Alzheimer’s Syndrome. To improve the Complainant’s spouse’s intake of nourishment and capacity to swallow and to speak, her oral surgeon recommended dental implants to hold the Complainant’s spouse’s lower denture in place. The Complainant’s spouse underwent dental surgery on November 12, 2001. Subsequently, the Respondent denied coverage for the surgery.
Dispute
Is the Respondent required to provide health benefits for the Pensioner’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Complainant: The Respondent is required to provide health benefits for the Pensioner’s spouse’s dental implant surgery because the procedure was medically necessary.
Position of the Respondent: The Respondent is not required to provide benefits for the Complainant’s spouse’s dental implant surgery because dental implants are not covered under the Employer Benefit Plan. Furthermore, dental prosthetic devices and dental service are specifically excluded under the Plan.
Pertinent Provisions
Article III. A. (3)(e) of the 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 the direct result of an accident
Article III. A. (7) (a) 1. of the Employer Benefit Plan states:
(7) Other Benefits
(a) Orthopedic and Prosthetic Devices
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
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
Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Article III. A. (3)(e) of the Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Charges for dental and oral surgical procedures may also be covered under the Employer Benefit Plan only when the procedures are performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. (See RODs 84-362, 84-442, and 84-564.) Dental services are otherwise excluded under Article III. A. (11) (a) 19. of the Plan. In addition, Article III. A. (7) (a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.
A Funds’ medical consultant has reviewed this case and has advised that the implant procedure in question is not one of the limited oral surgical procedures covered under Article III. A. (3)(e) of the Coal Act Employer Benefit Plan. Furthermore, the medical consultant notes that the Coal Act Employer Benefit Plan does not cover dental orthopedic and prosthetic devices.
Because the Complainant’s spouse’s dental implant surgery was not one of the covered oral surgical procedures and was not required as part of the treatment of an illness or injury that is otherwise a covered benefit, the Respondent is not required to provide coverage for the dental implants under the Coal Act Employer Benefit Plan.
Opinion of the Trustees
The Respondent is not required to provide coverage for the Complainant’s spouse’s dental implants under the Coal Act Employer Benefit Plan.