______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-086 - 1986年2月24日

董事会: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 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 coverage for dental services under the terms of the 雇主 Benefit Plan.

背景事实

In 1978 the 员工’s three-year old daughter was injured in an automobile 事故. The child’s five upper front teeth were knocked out as a result of the 事故. An orthodontist’s evaluation three days after the 事故 indicated that the extent of the damage and the resultant problems could not be determined until her permanent teeth came in. Re-evaluation was recommended when her permanent teeth came in at age twelve. In 1985, when the 员工’s daughter was almost 12 years old, she was re-evaluated. The orthodontist identified several dental problems which, 在他看来, resulted from the automobile 事故. They included deformed and discolored upper front teeth as well as a missing tooth. Orthodontia and subsequent crown and bridge work were recommended; the orthodontic treatment was begun. The 雇主 denied payment for orthodontic services on the grounds that dental services are not covered by the 雇主 Benefit Plan.

问题或争议

Is the 雇主 responsible for providing benefits for dental services required as the direct result of an 事故?

各方立场

Position of the 员工: The 雇主 is responsible for providing benefits for dental care the 员工’s daughter needs as a result of an automobile 事故.

Position of the 雇主: The 雇主 is not responsible for providing benefits for dental services.

相关的规定

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

(e) 口腔外科

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
面骨骨折
Frenulectomy when related only to ankyloglossia
(舌头领带)
Temporomandibular Joint Dysfunction, only when
medically necessary and related to oral orthopedic problem.
口腔活组织检查
Dental services required as a direct result of an
事故

讨论

根据第三条. A. (3) (e) of the 1984 雇主 Benefit Plan, benefits are payable for dental services required as a direct result of an 事故. The 事故al injury in this case occurred prior to the October 1, 1984 effective date of the Plan provision under which dental services required as a result of an 事故 are covered. 然而, the services in question were performed after the coverage effective date. It was necessary to defer the dental and orthodontic work on the 员工’s daughter until her permanent teeth came in and the services were performed as soon as it was medically feasible to provide them.

Two prior ROD opinions are relevant to this case. In ROD 57, the 员工 sustained an eye injury in August 1977 and had the eye removed in June 1978. In ROD 316, the 员工 injured his leg in December 1975 and had the leg removed in November 1980. 在每种情况下, the 事故al injury occurred prior to March 27, 1978, the effective date of the 雇主 Benefit Plan’s provision for dismemberment benefits. The opinion of the Trustees in each case stated that the 雇主 was responsible for paying dismemberment benefits because the loss occurred after the effective date of the benefit. 除了, the Plan does not exclude benefits for services required to treat pre-existing conditions. Benefits are therefore payable under Article Ill. A. (3) (e) for dental services required as the direct result of an 事故, 前提是, 在这些情况下

the 事故 occurred prior to October 1, 1984, the services were provided as soon as it was medically feasible to do so.

受托人的意见

The 雇主 is responsible for providing benefits for the 员工’s daughter’s dental services required as the direct result of an 事故.