受托人的意见
争议的解决
情况下没有. 84-156
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
84-156——1986年12月17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 (“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 oral surgery under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse has been treated by a 医生tor of osteopathy on multiple occasions for temporomandibular joint dysfunction (TMJ) which he states to be the result of a congenital defect of her maxilla (upper jaw), 这被称为前喙症. 雇员配偶的症状包括慢性头痛和颈部疼痛, 咀嚼和吞咽困难. The family physician has stated the surgical correction of the congenital defect is medically necessary to improve her TMJ dysfunction and referred her to an oral surgeon for further evaluation.

The oral surgeon has recommended surgical correction of the 员工’s spouse’s skeletal defect consisting of sectioning the upper jaw to allow for its advancement and posterior repositioning of the lower jaw to correct the skeletal horizontal deficiency. He states the 员工’s spouse is having problems with her temporomandibular joints secondary to the oral orthopedic problems. 雇主拒绝支付矫正手术的费用.

争端

Is the 雇主 responsible for the provision of health benefits coverage for the 员工’s spouse’s oral surgery?

各方立场

Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the 员工’s spouse’s oral surgery because the purpose of the surgery is to correct TMJ dysfunction.

受托人解决争议意见. 84-156
第二页

Position of the 雇主: The 雇主 is not responsible for the 员工’s spouse’s oral surgery because it is not one of the covered oral surgical procedures under 第三条. A. (3)(e).

第三条有关规定. A. 1984年雇主福利计划第(3)(e)条规定:

(e)口腔外科

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)
颌骨骨折，包括复位和固定
面骨骨折
Frenulectomy when related only to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, 只有在医疗需要的时候

口腔的活组织检查

因事故直接造成的牙科服务. A. (1) (g):

(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.

讨论

根据第三条. A. (3)(e)雇主福利计划, benefits are provided for oral surgery to treat temporomandibular joint dysfunction when medically necessary and related to an oral orthopedic problem. 第三条. A. (1)(g) provides hospitalization benefits for the oral surgical procedures described in 第三条. A. (3)(e)，但因医疗需要住院. 此外，根据Q&A #81-15(随函附上), certain dental and oral surgical procedures are covered under the 雇主 Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. Q&第81-16条(附在这里)规定了医生的服务, 包括麻醉服务, are a covered benefit only when they are for the treatment of a medical condition for which benefits would otherwise be provided.

受托人解决争议意见. 84-156
第3页

A Funds’ medical consultant has reviewed the medical evidence submitted and advised that insufficient medical justification has been provided to establish that the 员工’s spouse’s oral surgery was medically necessary or that a pre-existing medical condition existed to satisfy the requirements of 第三条. A. (1)(g). or that the surgery described by the oral surgeon could be considered part of the treatment of an otherwise covered medical condition.

Because of the provider’s failure to establish clearly that the 员工’s spouse’s oral surgery is one of the procedures listed in 第三条. A. (3)(e), or that it is due to a pre-existing medical condition which would satisfy the requirements of 第三条. A. (1)(g)或属于其他承保福利的治疗的一部分, the 员工’s spouse’s oral surgery to correct her claimed skeletal horizontal deficiencies, 上颌后颌和下颌前颌, 是否不受雇主福利计划保障.

With regard to the 员工’s statement that CNA insurance would have covered the expenses incurred for his wife’s orthodontic treatment and oral surgery, CNA was the dental insurance carrier for the 雇主 before Provident became the current carrier. Inasmuch as dental benefits are provided under Article XX-A of the Coal Wage Agreement and the Trustees have authority to resolve disputes involving benefits established by Article XX only, 受托人不得处理有关牙科计划福利的争议.

受托人的意见

The 雇主 is not responsible for providing health benefits coverage for the 员工’s spouse’s oral surgery or hospitalization for treatment of her claimed congenital defect.