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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: 88-217 - 1990年2月15日
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 for dental implant surgery under the terms of the 雇主 Benefit Plan.
背景事实
1987年6月, the 养老金领取者’s spouse had an intrabony dental implant system placed to help secure an ill-fitting lower denture. Her oral surgeon states that the original implant system was not tolerated, and it had to be removed. In December 1988, she had new intrabony dental implants placed on the mandible.
The 雇主 provided benefits for the implant system in 1987. The 养老金领取者 therefore contends that the 雇主 should provide benefits for the replacement procedure under the 雇主 Benefit Plan.
争端
Is the 雇主 required to provide health benefits for the 养老金领取者’s spouse’s dental implant surgery?
双方立场
Position of the 养老金领取者: The 雇主 is required to provide health benefits for the 养老金领取者’s spouse’s dental implant surgery because benefits were provided for dental implant surgery in the past.
Position of the 雇主: The 雇主 is not required to provide benefits for the 养老金领取者’s spouse’s dental implant surgery because it is not among the limited oral surgical procedures covered under the 雇主 Benefit Plan and because there is no evidence that the surgery is part of an otherwise covered treatment, 如Q所述&A 81-15. 此外, because the Plan specifically excludes benefits for dental prosthetic devices, it is the 雇主’s position that dental implants are also not covered.
相关的规定
第三条. A. (3)(e) 的“雇主福利计划”规定:
(3) Physicians’ Services and Other Primary Care
(e) 口腔外科
Benefits are not provided for dental services. 然而, benefits are provided for the following limited oral surgical procedures if performed by a dental surgeon or general surgeon:
Tumors of the jaw (maxilla and mandible)
Fractures of the jaw, including reduction and wiring
面骨骨折
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. 的“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.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
第三条. A. (11) (a) 19. 的“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, benefits are also not provided for the following:
…
19. 牙科服务.
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. (3)(e)雇主福利计划 specifies the limited oral surgical procedures for which benefits are provided. 根据Q&A 81-15(附副本), charges for dental and oral surgical procedures may also be covered under the 雇主 Benefit Plan only when the procedures are performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. 牙科服务 are otherwise excluded under 第三条. A. (11) (a) 19. 计划的详情. 此外，第三条. A. (7) (a) 1. 计划的详情 specifically excludes benefits for dental prosthetic devices.
A Funds’ medical consultant has reviewed this case and has advised that the implant procedure in question is not one of the oral surgical procedures covered under 第三条. A. (3)(e)雇主福利计划. The medical consultant has further stated that there is no medical evidence that the implant surgery was necessary as part of the treatment of an illness or injury that is otherwise a covered benefit. 因此, the 雇主 is not required to provide benefits under the 雇主 Benefit Plan for the surgical placement of the 养老金领取者’s spouse’s dental implants. The fact that the 雇主 may have paid benefits for a procedure in the past does not make the procedure a covered benefit.
受托人的意见
The 雇主 is not required to provide health benefits under the 雇主 Benefit Plan for the 养老金领取者’s spouse’s dental implant surgery.