______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
投诉人:被投诉人:ROD案件编号:
在再保险
员工
雇主
84-128——1988年3月25日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长，受托人. 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 for the treatment of temporomandibular joint dysfunction under the terms of the 雇主 Benefit Plan.
背景事实
On January 23, 1985, the 员工’s spouse had surgery for temporomandibular joint (TMJ) dysfunction. The pre-surgical diagnosis was bilateral internal derangement of the temporomandibular joints. The surgical procedure involved a repair of the right and left joints and surrounding ligaments. 手术前, the 员工’s spouse was treated with a splint in an effort to relieve the symptoms associated with the dysfunction.
The 员工’s spouse also received health benefits coverage from a group health insurance plan offered by her employer. 小组计划, which was primary to the 雇主 Benefit Plan for provision of health benefits to the 员工’s spouse, 支付手术费用, 以正常合理的收费金额为限, 还有住院费用. Deductibles and patient co-insurance amounts are applied by the group plan.
The 雇主 has denied payment for that portion of the surgical procedure and hospital charges which were not paid by the primary group plan because prior approval from the Plan Administrator was not obtained. The 员工 and his spouse state that they were not aware of a prior approval requirement for the surgery.
问题或争议
Is the 雇主 responsible for payment of benefits for the hospital and surgical services rendered the 员工’s spouse for treatment of temporomandibular joint dysfunction?
受托人解决争议意见. 84-128
第二页
各方立场
Position of the 员工: The 雇主 is responsible for payment of benefits for the surgical expenses incurred in treatment of the 员工’s spouse for temporomandibular joint dysfunction.
Position of the 雇主: The 雇主 is not responsible for payment of benefits for the surgical expenses incurred in treatment of the 员工’s spouse for temporomandibular joint dysfunction because prior approval was not obtained.
第三条有关规定. A. 雇主福利计划第(1)(g)条规定:
(g)口腔外科/牙科手术
Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in paragraph (3) (e) provided hospitalization is medically necessary.
Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.
第三条. A. 雇主福利计划(3)(e)规定:(e)口腔手术
牙科服务不提供福利. 然而, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon:
颌骨肿瘤(上颌骨和下颌骨)
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 the oral cavity
因事故直接造成的牙科服务. A. 《皇冠搏彩中心网站》(10)(f)的相关部分规定:
受托人解决争议意见. 84-128
第3页
(f) Non-Duplication
The health benefits provided under this Plan are subject to a non-duplication provision as follows:
(i) The Plan covering the patient other than as dependent will be the primary plan.
讨论
第三条. A. (I)(g) of the 1984 员工 Benefit Plan provides benefits for a Beneficiary who is admitted to a hospital for the limited oral surgical procedures described in 第三条. A. (3)(e)因医疗需要住院的. 根据第三条. A. (3)(e)雇主福利计划, benefits are provided for certain limited oral surgical procedures performed by a dental surgeon or general surgeon. Temporomandibular joint dysfunction is one of the surgical procedures covered under the 雇主 Plan.
In this case, the 员工’s spouse was under the care of an oral surgeon for TMJ dysfunction. She was admitted to the hospital for an oral surgical procedure which was covered under 第三条. A. (3)(e)雇主福利计划, and the hospitalization was therefore also covered. 根据计划, prior approval is not required for the surgical procedure or for the hospitalization.
The 员工’s spouse received primary health benefits coverage from another group plan. 根据第3条的不重复规定. A. (10)(f), benefits provided by the 雇主 Benefit Plan are reduced by the amount of benefits paid by the primary group plan.
受托人的意见
The 雇主 is responsible for payment of the charges associated with the 员工’s spouse’s oral surgery and related hospitalization, 以不重复的福利规定为限.