受托人的意见
争议的解决
情况下没有. 81-31
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 concerning coverage of dental services under the Employer’s Benefit Plan and hereby render their opinion on the matter.

背景事实

The Employee’s son was injured in a motorcycle accident on April 21, 1981, in which he sustained a fractured jaw, 牙齿脱落, 断裂的牙齿, 口腔伤口, 腹内损伤. He was admitted to the hospital where he underwent intra-abdominal surgery as well as two surgical procedures, 4月24日, 1981年5月4日, 1981, for repair of multiple mandibular fractures.

On August 24, 1981, the patient was referred to a dentist for reconstruction of the missing teeth. Coverage of the dental treatment provided on August 24, 1981, has been denied.

问题或争议

Is the Employer responsible for payment of the charges for procedures related to the restoration of the patient’s teeth performed on August 24, 1981?

各方立场

Employee: The Employee feels that the charges for the restorative dental services are covered because they were the direct result of the motorcycle accident.

Employer: The Plan Administrator bases its denial of coverage for the restoration services on Q&A #48 (subject matter contained in Q&A #81-15).

相关的规定

原告:
被申请人:
ROD 情况下没有: 81-31, 1982年7月27日

员工的雇主

受托人的意见 争议的解决 情况下没有. 81-31
第二页

第三条. A. (3) (e) of the Employer’s Plan which provides as follows:

“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) Temporomandibular Joint Dysfunction, 只有在医学上

necessary and related to an oral orthopedic problem Biopsy of lesions of the oral cavity

第三条. A. (11) (a) 19 of the Employer’s Plan which specifically excludes dental services from coverage.

Q&A # 81-15

Subject: Dental and Oral Surgical Services

References:Amended 1950 and 1974 Benefit Plans and Trusts, 第三条, Section A (3) (e)

其他:1981年合同Q&A #81-16

问题:
Are the following dental and oral surgical procedures covered under the Plan:

a. 拔牙?
b. gingevectomy, alveolectomy, operculectomy? c. gingivoplasty, alveoplasty, destibuloplasty?
d. 治疗牙齿脓肿?
e. 下颌骨前突切除术?
f. 下颌骨钉?
g. 口腔正畸学?

答:

The dental and oral surgical procedures listed above, 当在医院进行时, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the 拔牙 during emergency treatment of extensive facial damage resulting from an auto accident; (2) the 拔牙 during treatment of cancers of the head and mouth; and (3) the insertion of a 下颌骨钉 to repair a fractured jaw.

受托人的意见 争议的解决 情况下没有. 81-31
第3页

Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.

讨论

根据第三条. A. (3) (e) of the Employer’s Benefit Plan, dental services are specifically excluded as a covered service. 问下&A #81-15, certain dental and oral surgical procedures are covered, but only 当在医院进行时 as part of treatment for an illness or injury which is a covered benefit.

The specific services in dispute in this case are those related to restorative dental procedures provided on August 24, 1981, approximately four months after the Employee’s son’s accident. Because these services were not part of the emergency treatment of the traumatic injuries, and are not an otherwise covered benefit, they are excluded from coverage by the Employer’s Benefit Plan.

受托人的意见

The Trustees are of the opinion that the Employer is not responsible for payment for the restorative dental services provided on August 24, 1981, 给雇员受抚养的儿子.