受托人的意见
Resolution of 争端
情况下没有. 84-447
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

员工
雇主
84-447 – 1988年1月5日

Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人,; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits for oral surgery under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s orthodontist has diagnosed the 员工 as having maxillary sagittal hypoplasia, mandibular sagittal hyperplasia, severe malocclusion and transverse hyperplasia of the maxilla. He characterizes the malocclusion as a severe skeletal Class III relationship of the maxillary and mandibular jaw bones which requires correction to help the teeth function properly, to prolong their longevity and to improve mastication. He placed orthodontic appliances and referred the 员工 to an oral surgeon for orthognathic surgery. The 员工’s request for prior approval for sagittal mandibular and Leforte I maxillary osteotomies with an internal rigid fixation to correct the malocclusion was denied by the 雇主.

The 员工 contends that the orthognathic surgery is medically necessary and that it should be a covered benefit as he was an active miner when he first attempted to get prior approval for the surgery.

The 雇主 stated that that 员工’s proposed oral surgical procedures are not among the limited oral surgical procedures covered under the 雇主 Benefit Plan. Therefore, the proposed oral surgery and any hospital charges related to it are not covered benefits.

The 雇主 further stated that although the limited oral surgical procedures are covered in accordance with a fixed fee schedule under the 雇主’s Dental Plan, because the 员工 is presently on layoff status, his dental coverage is terminated and will not be reinstated until he returns to active employment with the 雇主.

争端

受托人的意见 Resolution of 争端 情况下没有. 84-447
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Is the 雇主 responsible for the provision of health benefits coverage for the oral surgeon’s fee and for the hospitalization charges for the 员工’s proposed oral surgery?

Positions of the Parties

Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the 员工’s proposed oral surgery because it is medically necessary, and the 员工 was an active miner at the time he first requested prior approval for it.

Position of the 雇主: The 雇主 is not responsible for the provision of health benefits for the oral surgeon’s fee and the related hospital charges because the proposed surgery is not one of the covered oral surgical procedures under 第三条.A. (3)(e). The 雇主 is not responsible for the provision of dental benefits under the 员工’s Dental Plan because he is presently on layoff status and his dental coverage is terminated.

Pertinent Provisions 第三条.A. (1)(g) of the 雇主 Benefit Plan states:

(g) Oral Surgical/Dental Procedures

Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (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 preexisting medical condition, and prior approval is received from the Plan Administrator.

第三条. A. (3)(e) of the 雇主 Benefit Plan states: (e) Oral Surgery

Benefits are not provided for dental services. 然而, 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)

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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

讨论

第三条. A. (3)(e) of the 雇主 Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. A Funds’ medical consultant has reviewed the information submitted by the orthodontist and the oral surgeon and has advised that the oral surgical procedures outlined therein, sagittal mandibular and LeForte I maxillary osteotomies with an internal rigid fixation, are not among those procedures covered by 第三条. A. (3)(e).

In addition, according to Q&A 81-15 (copy enclosed herein), certain charges for services for dental and oral surgical procedures are covered under the 雇主 Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. 再一次。, no evidence has been submitted to establish that this surgery is medically necessary to treat an otherwise covered medical problem or illness. The orthodontist described dental problems such as a severe malocclusion and a difficulty with mastication; he did not state that either problem was related to a medical condition which needs to be treated by the surgery in question.

第三条. A. (I)(g) of the 雇主 Benefit Plan provides benefits for medically necessary hospitalization for oral surgical procedures when the admission is for one of the oral surgical procedures listed in 第三条. A. (3)(e). That Article also states that inpatient hospital benefits are provided when, because of beneficiary’s preexisting medical condition, hospitalization for a dental procedure is necessary and prior approval has been received from the Plan Administrator. A Funds’ medical consultant reviewed information submitted by the 员工’s orthodontist and oral surgeon and found no evidence of a preexisting medical condition that would indicate that hospitalization was necessary.

Inasmuch as the oral surgical procedures performed on the 员工 are not among the covered procedures under 第三条. A. (3)(e) and were not performed as part of the treatment for an otherwise covered benefit, 如Q所述&A 81-15, the oral surgeon’s fee is not covered under the 雇主 Benefit Plan. 此外, inasmuch as the 员工’s hospitalization would not be necessitated by a preexisting medical condition, coverage under 第三条. A. (1)(g) of the 雇主 Benefit Plan has been correctly denied.

Dental benefits are provided under Article XX-A of the Coal Wage Agreement. The Trustees have authority to resolve disputes only involving benefits established by Article XX. Therefore, the Trustees may not address disputes concerning Dental Plan benefits.

Opinion of the Trustees

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The 雇主 is not responsible for payment of the charges related to the professional services or the hospitalization for the 员工’s oral surgery under the terms of the 雇主 Benefit Plan.