受托人的意见
争议的解决
情况下没有. 88-061
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

员工

雇主
88-061 - 1989年3月3日

在再保险

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 coverage for anesthesia services and hospitalization related to the performance of dental procedures under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s dependent son was seen by a dentist when he was five years old for the treatment of nine teeth which had extensive and advanced carious lesions. The dentist stated that due to the extensive nature of the dental work and the high level of anxiety exhibited by the child, 有必要进行牙科治疗, 填充物和牙冠, 在医院门诊部接受全身麻醉. The dentist stated that the child exhibited no systemic complications and had no history of medical conditions which influenced his decision to use general anesthesia when the treatment was performed on May 25, 1988.

The 雇主 paid the dentist for his services up to the scheduled amount under the Dental Plan. It denied payment under the 雇主 Benefit Plan for the anesthesia services and the outpatient hospital expenses related to the dental procedures performed on the 员工’s son.

争端

Is the 雇主 required to provide benefits under the 雇主 Benefit Plan for the anesthesia and outpatient hospital charges associated with the 员工’s son’s dental treatment?

双方立场

受托人解决争议意见. 88-061
第二页

Position of the 员工: The 雇主 is required to provide health benefits under the 雇主 Benefit Plan for the anesthesia and hospital charges associated with the 员工’s son’s dental treatment.
Position of the 雇主: The 雇主 is not required to provide health benefits under the 雇主 Benefit Plan for the anesthesia and outpatient hospital charges because there was no preexisting medical condition which necessitated hospitalization for the dental procedures and because prior approval was not obtained from the Plan Administrator.

第三条有关规定. A. 雇主福利计划第(1)(g)条规定:

(1)住院医疗福利
(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 preexisting medical condition and prior approval is received from the Plan Administrator.

第三条. A. (3)(e) of the 雇主 Benefit Plan states: (3) Physicians’ Services and Other Primary Care

(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

并与口腔整形问题有关口腔活检

因事故直接导致需要牙科服务的讨论

受托人解决争议意见. 88-061
第3页

第三条. A. (1)(g) of the Plan provides that hospital benefits are provided for (1) beneficiaries admitted for the oral surgical procedures described in 第三条. A. (3)(e), 如果需要住院治疗, and (2) beneficiaries admitted for dental procedures if hospitalization is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator.

雇员的儿子作为医院的门诊病人接受了补牙和冠手术. A Funds’ medical consultant has advised that the dental work performed in this case is not one of the oral surgical procedures identified in 第三条. A. (3)(e). 因此，第三条第一款不包括住院费用. A. (1)(g)如上所述.

另有根据第三条提供的福利. A. (1)(g) if hospitalization for dental procedures is necessary due to a preexisting medical condition and prior approval is received from the Plan Administrator. The dentist conducted the dental work in the hospital because of the 员工’s son’s anxiety and the extensive nature of the dental work. The dentist specifically stated that the hospitalization was not necessitated by a preexisting medical condition. 除了, it is clear that the 员工 did not obtain prior approval from the Plan Administrator. 因此，不提供医院费用补贴.

Q&81-16(附副本)规定，医生服务, 包括麻醉服务, provided in connection with a hospitalization for a non-covered dental procedure may be covered if (1) the hospitalization is medically necessary due to a preexisting medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. 如上所述, the hospitalization of the 员工’s son was not necessitated by a preexisting medical condition. 除了, a Funds’ medical consultant found no evidence that the use of anesthesia in this case was related to the treatment of any otherwise covered medical condition. 雇员的儿子接受的治疗是为他的牙科手术. 因此，麻醉费用不提供福利.

受托人的意见

The 雇主 is not required to provide benefits under the 雇主 Benefit Plan for the anesthesia and outpatient hospital charges resulting from the 员工’s son’s dental treatment on May 25, 1988.