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OPINION OF TRUSTEES
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In Re

Complainant: Pensioner
Respondent: Employer
ROD Case No: 84-442 – December 15, 1987

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.

根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了有关根据雇主福利计划条款提供植牙健康福利的争议的事实和情况.

Background Facts

1979年，这位退休老人的配偶在下颌骨上植入了骨膜下植入物. 从那时起，她一直持续感染，下颌骨持续脱落. 植入物目前暴露并感染，需要移除. 养老金领取者的配偶的规定治疗是在她的下颌骨上放置大约五个种植体，这将为永久性固定下颌骨假体的建造提供基础.

The Employer paid for the subperiosteal implant in 1979, 并且领取养老金的人认为它应该根据雇主福利计划或雇主牙科计划再次为该程序提供福利.

雇主拒绝在雇主福利计划下为拟议的口腔手术提供保险，因为它不在第三条规定的有限口腔外科手术范围内. A. (3)(e)由于本计划明确排除了牙科修复装置的福利. 雇主还声明，其牙科计划特别不包括牙科种植和, furthermore, 领取养老金者及其家属没有资格享受牙科计划的福利.

Dispute

雇主是否负责为退休人员配偶的植牙手术提供健康福利?

Positions of the Parties

申诉人的立场:雇主负责为养恤金领取者配偶的植牙手术提供医疗福利，因为1979年就为同一手术提供了福利.

答辩人的立场:雇主不负责根据雇主福利计划为领取退休金者配偶的植牙提供福利，因为植牙所代表的牙科服务并不包括在雇主福利计划内. 雇主的牙科计划特别不包括牙科种植和, furthermore, 投诉人及其受养人没有资格享受牙科计划的福利.

Pertinent Provisions

Article III. A. (3)(e) of the 1984 Employer Benefit Plan states:

(e) Oral Surgery

Benefits are not provided for dental services. However, 如果由牙科医生或普通外科医生进行以下有限的口腔外科手术，则可获得福利:

Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
Fractures of the facial bones
仅与强直性舌结(舌系带)有关的系带切除术
Temporomandibular Joint Dysfunction, 只有在医学上必要且与口腔整形问题有关的情况下
Biopsy of the oral cavity
因事故直接导致需要牙科服务

Article III. A. (7) (a) 1. of the 1984 Employer Benefit Plan states:

(7) Other Benefits

(a) Orthopedic and Prosthetic Devices

在医疗上必要时，由医生开具的矫形和假体装置提供福利.

The following types of equipment are covered:

1. 假体装置，用来代替身体的内部或外部部分，牙齿除外.

Article III. A. (11) (a) of the 1984 Employer Benefit Plan states in part:

(11) General Exclusions

(a) 除本计划中另有规定的特定除外事项外, benefits are also not provided for the following:

19. Dental services.
Q&A 81-15 states:

Subject: Dental and Oral Surgical Services

References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III. Section A (3) (e)

Other: 1981 Contract Q&A #81-16

Question:

下列牙科及口腔外科手术是否包括在本计划内?

a. extraction of teeth?
b. gingivectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?

Answer:

The dental and oral surgical procedures listed above, when performed in a hospital, 只有当它们是治疗疾病或受伤的一部分时才被包括在保险范围内. Examples of this would be: (I), the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident: (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.

除上段规定外，上述七项程序均不包括在《官方网站》内.

Discussion

牙种植体用于将替代牙齿附着在牙龈或口腔骨骼上. Article III. A. (II) (a) 19. of the Employer Benefit Plan, as well as Q&A 81-15 (copy enclosed herein), 特别不包括牙科服务，除非在非常有限的情况下. 本案不涉及这些有限情况之一. In addition, Article III. A. (7)(a) 1. 本计划特别排除了牙科修复装置的福利.

Article III. A. (3)(e) of the Employer Benefit Plan provides benefits for certain limited oral surgical procedures; however, 因为为领取退休金者的配偶推荐的牙科治疗不涉及这些有限的外科手术之一, it does not qualify for coverage under this provision. 雇主过去可能为某一程序支付过福利，并不使该程序成为承保福利.

由于牙科福利是根据煤炭工资协议第XX- a条规定的，受托人有权解决仅涉及第XX条规定的福利的争议, 受托人不得处理有关牙科计划福利的争议.

Opinion of the Trustees

雇主不负责根据雇主福利计划为领取退休金者配偶的植牙治疗提供健康福利.