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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-396——1987年11月11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

该雇员的配偶于10月7日去看了牙科医生, 1985年，主诉慢性面部疼痛. The dental surgeon determined that she suffered from advanced mandibular atrophy and recommended oral surgery to correct the problem. The dental surgeon has indicated that prior approval was obtained for hospitalization after submitting a comprehensive description of her medical condition, 其中包括动脉高血压和甲状腺功能亢进的病史. 5月1日, 1986, the dental surgeon placed reconstructive bone grafts to the left and right posterior mandible, placed a mandibular bone plate staple implant and repositioned the mandibular nerves.

The 雇主 denied coverage for the oral surgeon’s fees because the surgery was not one of the limited oral surgical procedures covered under 第三条. A. (3)(e)雇主福利计划. The 员工 claims that the oral surgical procedures should have been covered under the 雇主 Benefit Plan because the 员工 s spouse’s bone loss was congenital in nature and prior approval was obtained. Certain hospitalization benefits were paid by the 雇主 and have not been disputed by the 员工.

手术后，雇员的配偶已装上假牙. 雇主拒绝在其牙科计划下为假牙提供保险. The 员工 alleges that new dentures were required as a result of the surgery, 因此, 它们应该是有保障的福利.

争端

Is the 雇主 responsible for providing health benefits coverage for the 员工’s spouse’s oral surgery and dentures?

双方立场

Position of the 员工: The 雇主 is responsible for providing health benefits coverage offer 员工’s spouse’s oral surgery and dentures.

Position of the 雇主: The 雇主 is not responsible for providing health benefits coverage for the dental surgeon’s fee 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)雇主福利计划. The 雇主 is not responsible for coverage for dentures under its dental plan because such benefits are limited to once every five years and benefits were provided about two years ago.

相关的规定

第三条. A. (11)(a) 19. 1984年雇主福利计划规定:

(11) 一般的除外

(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:

19. 牙科服务.

第三条. A. 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
仅与强直性舌结(舌系带)有关的系带切除术
颞下颌关节功能障碍, only when medically necessary and related to an oral orthopedic problem
口腔活组织检查
因事故直接导致需要牙科服务

讨论

第三条. A. (3)(e)雇主福利计划 specifies the limited oral surgical procedures for which benefits are provided. A Funds’ medical consultant has reviewed the information submitted by the dental surgeon and has advised that the surgical procedures performed, 骨移植和植入, 不属于第三条规定的有限程序. A. (3)(e). 此外，根据Q&A 81-15(附副本), charges for services for 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. No medical evidence has been submitted to substantiate the position that the patient’s oral surgical procedures were performed as part of the treatment of an otherwise covered illness or injury. Inasmuch as oral surgical procedures performed on the the 员工’s spouse are not among the covered oral surgical procedures listed in 第三条. A. (3)(e) and were not performed as part of the necessary treatment for an illness or injury that is otherwise a covered benefit, the professional service fees are not covered under the 雇主 Benefit Plan.

The 雇主 has waived the prior approval requirement for hospitalization benefits in this case based upon a determination that the outpatient hospital setting was appropriate and necessary due to the 员工’s spouse’s pre-existing medical conditions. Consequently, certain hospitalization benefits were paid by the 雇主. Professional fees for the oral surgery were not included in the charges which the 雇主 agreed to pay.

With respect to the 员工’s claim that his spouse’s dentures are a covered benefit, 第三条. A. (11) of the 雇主 Benefit Plan specifically excludes coverage for dental services under the Plan. 此外, 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, the Trustees may not address disputes concerning dental plan benefits.

受托人的意见

The 雇主 is not responsible for the provision of health benefits for the 员工’s spouse’s oral surgery.