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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: CA-025 – January 10, 2001
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 Health Benefit Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
Background Facts
On September 9, 1993, the Pensioner’s spouse had a free gingival graft to replace tissue loss resulting from lichen planus, a chronic condition of the oral mucosa, which was performed in the oral surgeon’s office.
According to the Explanation of Benefit statement submitted by the Pensioner, coverage for the procedure was denied because the Pensioner’s coverage does not include dental benefits.
Dispute
Is the Employer required to provide benefits for the Pensioner’s spouse’s oral surgery?
Positions of the Parties
Position of the Complainant: The Employer is required to provide benefits for the Pensioner’s spouse’s oral surgery because the procedure was necessary to treat a chronic medical problem.
Position of the Respondent: The Respondent has not responded to repeated correspondence requesting its position in this dispute.
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 the direct result of an accident.
Article III. A. (11) (a) 19. states in pertinent part:
(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) of the Coal Act Employer Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Article III A. (11) (a) 19. excludes benefits for dental services.
A Funds’ medical consultant reviewed the documentation submitted with this case and concluded that the free gingival graft to replace tissue lost to lichen planus is not one of the limited oral procedures covered by Article III A. (3) (e) of the Coal Act Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required under the provisions of the Coal Act Employer Benefit Plan to provide health benefits coverage for the Complainant’s spouse’s oral surgery on September 9, 1993.