受托人的意见
连杆箱编号. 30
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

在再保险

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人

Pursuant to Article IX of the United Mine Workers of America 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 about the level of health benefits provided to an Employee’s dependent by an Employer and hereby render their opinion of the matter.

背景事实

Complainant is an active employee of Employer. On July 9, 1978, the Employee’s two dependent children consulted a physician for severe toothaches. The physician diagnosed their problem as severely impacted wisdom teeth and admitted them the same day to a local hospital. 第二天, each dependent had four impacted wisdom teeth surgically removed, under general anesthesia by an oral surgeon. They were discharged from the hospital the following day.

The oral surgeon who performed the surgery has stated that, “Due to the severity of the impaction, it was necessary to hospitalize (the) patient(s) for general anesthesia and follow up professional care”.

问题或争议

The Employee filed a claim for coverage of the hospitalization charges. The insurance company has denied payment on the claim, The Employer concurs with the insurance company’s decision,

双方立场

Claimant’s Position: The Employer (insurance company) is responsible for payment of the claim, since hospitalization for dental procedures 在本计划承保范围内, 基于1978年合同Q & A #88”.

原告:
被申请人:
连杆箱编号. 1979年8月22日

员工的雇主

受托人的意见
连杆箱编号. 30
第二页
Employer’s (Insurance Company’s) Position: The Employer (Insurance Company) is not responsible for payment of the claim, since hospitalization for dental procedures are not covered under the Plan, 基于Q & A #48.

国家有关规定

o Article III, Section A (1) (a) of the Employer Plan 规定如下:

When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient (overnight confinement) to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.

o 1978 Contract Question and Answer #48, as approved by the Trustees on June 21, 1978, 规定如下:

Questions:Are the following dental procedures covered under the 1978 Agreement:

a. 拔牙?
b. gingivectomy, alveolectomy, operculectomy? c. 龈成形术,alveoplasty?
d. 治疗牙齿脓肿?
e. 以上住院?

答:拔牙, 当在医院进行时, and costs associated with the extraction are covered only when they are part of a treatment for an illness or injury which itself is a covered benefit, Examples of this would be the 拔牙 during treatment for an auto accident involving extensive facial damage, or during treatment for cancers of the head and neck.

除了这项规定之外, none of the above procedures is covered under the 1978 Agreement, since dental services are specifically excluded from the coverage, except for those listed under the Oral Surgery benefit in Section A(3) (e). These include surgical treatment for:

-颌骨肿瘤
– fractures of the jaw, including reduction and wiring

受托人的意见书. 30
第3页

-面骨骨折
– frenulectomy, when related to ankyloglossia (tongue tie).

o 1978 Contract Question and Answer #88, 于四月十七日获受托人批准, 1979, 规定如下:

问题:答案:

Are hospitalization charges related to dental procedures covered under the Plan?

是的, when (1) medically necessary and (2) prior authorization has been obtained from the Plan Administrator.

讨论

凭借Q & A #88, 住院接受牙科治疗, such as the Employee’s children underwent, 在本计划承保范围内. 这个问 & A打算取代Q & A #48, and renders part (e) of the question to #48 no longer in effect.

A UMWA District official representing the claimant brought Q & A #88 to the attention of the Employer’s Labor Commissioner, who had been handling the Employee’s grievance on this issue, Q之后不久 & A由受托人批准.

受托人的意见

The Trustees are of the opinion that the Employer (Insurance Company) is required to cover the hospitalization charges incurred by the Employee’s dependent children. (Prior authorization must be obtained by the Plan Administrator for hospitalization for dental care, Q的生效日期&A #88 has been published and received by the Plan Administrator.)