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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 1980年3月24日

Board of Trustees: Harrison Combs, Sr., 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 concerning dental benefits and hereby render their opinion on the matter.

背景事实

Complainant is an active mine worker eligible for health benefits under the 雇主’s Plan. 9月11日, 1979 the 员工’s dependent son, 6岁, was struck in the mouth by a see-saw, sustaining injuries to his central incisors requiring treatment consisting of x-rays and temporary restoration of the broken portions of the front teeth. The attending dentist indicated in his report that future treatment, 作为一个青少年, would include “possible crown and braces.”

问题或争议

Is the dental treatment required as a result of the accident a covered benefit?

各方立场

原告: The Insurance Carrier should provide coverage of the treatment due to the amount of damage to the dependent’s permanent teeth as a result of the accident.

被申请人: The Plan Administrator’s opinion is that based upon the information submitted and the fact that all services were rendered in a dentist’s office, 不是在医院里, coverage is specifically excluded by Q&A’s 48 and 88, as well as by specific provisions of the 雇主’s Plan.

Applicable Regulations

o Article III, Section A (3)(e) of the 雇主’s Plan provides as follows:

“Benefits are not provided for dental services. 然而, with approval of the Trustees, 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)”

o Article III, Section A (10)(a) 19 of the 雇主 Plan specifically excludes as follows:

“牙科服务”

o 1978 Contract Question and Answer #48 states that dental and oral surgical procedures 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.

讨论

Provisions of the Plan exclude coverage of dental services. In this case treatment consisted solely of x-rays, examination and temporary restoration of fractured teeth in the office of a dentist. No further treatment is projected until the patient reaches his teen years.

按照Q&A 48, benefits are provided for dental procedures such as those which were required in this case only when received in the hospital and then only in connection with repair of fractures or treatment of an illness such as cancer of the mouth.

受托人的意见

The Trustees are of the opinion that the Insurance Carrier is not responsible for coverage of the dental procedures resulting from the accidental injury in this case.