受托人的意见
争议的解决
情况下没有. 84-105
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

员工
雇主
84-105——1985年12月18日

Board of Trustees: Joseph Connors, Sr., 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 coverage for anesthesia services for a dental procedure under the terms of the 雇主 Benefit Plan.

背景事实

雇员的女儿, who is known to have cerebral palsy and an active seizure disorder, was hospitalized on December 14, 1984年牙科服务. The 雇主 has denied payment for the anesthesia charges resulting from this care.

争端

Is the 雇主 responsible for payment of the anesthesia charges incurred during the 员工’s daughter’s hospitalization for dental care on December 14, 1984?

各方立场

Position of the 员工: The 雇主 is responsible for payment of the anesthesia charges resulting from the 员工’s daughter’s hospitalization for dental rehabilitation.

Position of the 雇主: Coverage for anesthesia services was denied because the 员工’s daughter’s hospitalization for dental surgery was not related to the treatment of her pre-existing medical condition, and the anesthesia services were not part of the treatment for an otherwise covered medical condition.

相关的规定
第三条. A. (1) (g)和(III. A. (3) (d) of the 雇主 Benefit Plan state in relevant part:

受托人的意见 争议的解决 情况下没有. 84-105
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(1) (g)

(3) (d)

Oral Surgical/Dental Procedures

Benefits are also provided for a beneficiary admitted to 一个医院 for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.

麻醉服务

Benefits are provided for the administration of anesthetics provided either in or out of the hospital in surgical or obstetrical cases, when administered and billed by a physician, other than the operating surgeon or his assistant, 谁不是公司的雇员, 也没有补偿, 一个医院, laboratory or other institution.

讨论

第三条. A. (1) (9) provides benefits for hospitalization for dental procedures only if such hospitalization is necessary due to a pre-existing medical condition and when prior approval has been received from the Plan Administrator, 就像这次一样.

第三条. A. (3)(d) establishes the conditions under which anesthesia services are considered a covered benefit. Anesthesia for a dental procedure qualifies under this provision if it is necessary to assure proper medical management, 控制, or treatment of the patient in light of the underlying medical condition.

的资金’ consultant who reviewed this case concluded, based on medical information supplied by the beneficiary’s physician, that the hospitalization and general anesthesia were necessary due to the beneficiary’s pre-existing medical condition. 在她的牙医看来, the beneficiary’s cerebral palsy and seizure disorder prevented the oral surgeon from performing the required dental rehabilitation safely and effectively with local anesthesia. The use of a general anesthetic was therefore necessary in this case to permit the required services and to avoid harm to the patient. Under these circumstances, the pre-existing medical condition requirement of 第三条. A. 满足(1)(g). In addition, since the required anesthesia was provided in accordance with 第三条. A. (3) (d), it is a covered benefit under the terms of the 雇主 Benefit Plan.

受托人的意见

The 雇主 is responsible for the payment of the anesthesia charges resulting from the 员工’s dependent’s dental care on December 14, 1984.