Opinion of Trustees
Resolution of Dispute
Case No. 88-021
Page 1 ______________________________________________________________________________

对受托人的看法 ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

In Re

Employee
Employer
88-021 – December 12, 1988

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, and under the authority of an exception granted by the United States Department of Labor, 受托人审查了有关根据雇主福利计划条款提供口腔手术健康福利的争议的事实和情况.

Background Facts

An orthodontist diagnosed the Employee’s dependent daughter as having a severe Class II, bi- maxillary protrusion malocclusion. 他认为错牙合是一种发育畸形，本质上是骨骼和牙齿的畸形. 正畸医生将雇员的女儿转介给口腔外科医生，口腔外科医生称严重的开咬畸形影响了她咀嚼食物的能力, and that she has severe temporomandibular joint (TMJ) dysfunction. 正畸医生使用牙套为雇员女儿的牙齿做手术治疗准备, a maxillary osteotomy, recommended by the oral surgeon. 雇员要求事先批准拟议的口腔手术，但被雇主拒绝. 雇员认为保险应该提供，因为他女儿的情况是出生缺陷的结果.

雇主认为上颌截骨术不属于第三条所列的手术. A. (3)(e)雇主福利计划，且所提供的医疗信息不表明先前存在符合第三条要求的健康状况. A. (1 ( ) of the Plan. 因此，雇主坚持认为，拒绝支付拟议的口腔手术和有关住院费用是合理的.

The Employer states that since the proposed oral surgery is a non-covered procedure, the Employee’s claim that it is necessary to correct a birth defect is irrelevant.

Dispute

Opinion of Trustees Resolution of Dispute Case No. 88-021
Page 2

雇主是否负责为雇员女儿拟议的口腔手术及相关住院治疗提供健康福利?

Positions of the Parties

雇员职位:雇主负责为雇员女儿拟议的口腔手术提供健康保险，因为这是纠正出生缺陷所必需的.

雇主的立场:雇主不负责为雇员女儿的口腔手术提供健康保险，因为这不是第三条规定的口腔外科手术之一. A. (3)[e]. 雇主不负责提供有关住院费用的健康福利，因为先前存在的健康状况没有按照第三条的要求证明. A. (1)(g) of the Employer Benefit Plan.

Pertinent Provisions Article III. A. (1)(g) of the Employer Benefit Plan states:

(1) Inpatient Hospital Benefits
(g) Oral Surgical/Dental Procedures

如果受益人因医疗需要住院接受第(3)款(e)项所述的口腔外科手术，则向其提供补贴.

只有由于先前存在的健康状况而必须住院并事先得到计划管理人的批准，才可向住院接受牙科手术的受益人提供福利.

Article III. A. (3)(e) of the Employer Benefit Plan states: (3) Physicians’ Services and Other Primary Care

(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:

Opinion of Trustees Resolution of Dispute Case No. 88-021
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Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring Fractures of the facial bones
系带切除术仅与强直性咬合(舌结)颞下颌关节功能障碍有关, only when medically

necessary and related to an oral orthopedic problem Biopsy of the oral cavity

Dental services required as the direct result of an accident Discussion

Article III. A. 雇主福利计划的第(3)(e)条规定了提供福利的有限口腔外科手术. Among those procedures is surgery for temporomandibular joint dysfunction, under certain circumstances. A皇冠搏彩中心网站的医疗顾问审查了本案提交的资料，认为拟议的口腔外科手术不属于第三条所述的手术. A. (3)(e). 顾问还建议，该病例没有颞下颌关节功能障碍的医学记录，建议的手术是为了纠正正畸问题(开咬)。, not to specifically reorient the temporomandibular joint.

According to Q&A 81-15 (copy enclosed herein), 牙科和口腔外科手术的费用也可由雇主福利计划承担，但前提是该手术是作为治疗疾病或受伤的一部分在医院进行的，而该疾病或受伤在其他方面属于承保福利.
医疗顾问表示，没有提交任何证据证明拟议的手术在医学上是治疗其他承保的疾病所必需的.

Article III. A. (1)雇主福利计划(g)规定，如果住院接受第三条所列的口腔外科手术，则提供必要的医疗住院津贴. A. (3)(e). 如果由于受益人先前的健康状况而需要住院接受牙科手术，也提供住院住院津贴, and when prior approval has been received from the Plan Administrator. 医疗顾问建议说，没有证据表明先前存在疾病.

由于患者建议的口腔手术不是a)第III条所列的涵盖口腔外科手术之一. A. (3)(e)或(b)疾病或伤害治疗的一部分，否则属于承保福利, the professional services fees are not covered. Because the surgery is not one of the covered oral surgical procedures listed in Article III. A. (3)(e) and there is no evidence of a preexisting medical condition, the patient’s hospitalization does not meet the requirements for coverage under Article III. A. (1)(g).

Opinion of the Trustees

雇主不负责为雇员女儿拟议的口腔手术和住院提供健康福利.