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受托人的意见
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在再保险

原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 84-564——1988年2月24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 dental implants under the terms of the 雇主 Benefit Plan.

背景事实

The 养老金领取者’s spouse’s oral surgeon recommends that the 养老金领取者’s spouse have implants placed in her mouth to provide abutments for the replacement of her missing teeth. He states that implant surgery is performed in connection with restoration of teeth to assist in speech and in the mastication of food. He states that such surgery may also eliminate chronic nerve pain, preserve remaining bone structures and prevent the potential for pathologic fractures.

The 雇主 denied coverage under the 雇主 Benefit Plan for the proposed oral surgery because the placement of endosseous implants is not among the limited oral surgical procedures covered under 第三条.A. (3)(e)雇主福利计划. The 雇主 also stated that its Dental Plan specifically excludes benefits for dental implantology, 而且, 养老金领取者s and their dependents are ineligible for Dental Plan benefits.

争端

Is the 雇主 responsible for the provision of health benefits coverage for the 养老金领取者’s spouse’s dental implant surgery?

双方立场

Position of the 原告: The 雇主 is responsible for the provision of health benefits coverage for the 养老金领取者’s spouse’s dental implants.

Position of the 被申请人: The 雇主 is not responsible for the provision of benefits under the 雇主 Benefit Plan for the 养老金领取者’s spouse’s dental implants because they represent dental services, which are not covered under the 雇主 Benefit Plan. The 雇主’s Dental Plan specifically excludes benefits for dental implantology, and the 养老金领取者 and his dependents are ineligible for Dental Plan benefits.

相关的规定

第三条. 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
Fractures of the facial bones Frenulectomy when related only to ankyloglossia (tongue tie)
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
牙科服务 required as the direct result of an accident

第三条. A. (7) (a) 1. 1984年雇主福利计划规定:

(7) 其他好处

(a) 矫形和假体设备

Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.

包括以下类型的设备:

1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.

第三条. A. (11) (a) of the 1984 雇主 Benefit Plan states in part:

(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.

Q&81-15州:

主题: 牙科及口腔外科服务

引用:修改1950 & 1974年福利计划 & 信托，第三条. 一个节. (3) (e)

其他: 1981年合约Q&A #81-16

问题:

Are the following dental and oral surgical procedure covered under the Plan:

a. 拔牙?
b. 牙龈切除术，牙槽切除术，包膜切除术?
c. 牙龈成形术，牙槽成形术，前庭成形术?
d. 治疗牙齿脓肿?
e. 下颌骨前突切除术?
f. 下颌骨钉?
g. 口腔正畸学?

答:

The dental and oral surgical procedures listed above, 当在医院进行时, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the 拔牙 during emergency treatment of extensive facial damage resulting from an auto accident: (2) the 拔牙 during treatment of cancers of the head and mouth; and (3) the insertion of a 下颌骨钉 to repair a fractured jaw.

Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.

讨论

Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. 第三条. A. (11) (a) 19. 的雇员福利计划，以及Q&A 81-15, specifically excludes coverage for dental services except in specific circumstances. This case does not involve those specific circumstances. 此外，第三条. A. (7)(a) 1. of the Plan specifically excludes benefits for dental prosthetic devices.

第三条. A. (3)(e)雇主福利计划 provides benefits for certain limited oral surgical procedures. A Funds’ medical consultant has reviewed this case and has advised Employee’s spouse that the proposed implant surgery is not among the oral surgical procedures listed under 第三条. A. (3)(e). 因此, benefits are not provided under the 雇主 Benefit Plan for the surgical placement of the 养老金领取者’s spouse’s dental implants.

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 providing health benefits under the 雇主 Benefit Plan for the 养老金领取者’s spouse’s dental implant treatment.