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OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
88-340 - 1990年11月29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, 并根据美国劳工部授予的豁免授权, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for anesthesia services and hospitalization in connection with dental procedures under the terms of the 雇主 Benefit Plan.

背景事实

An oral surgeon recommended that the 员工’s spouse be hospitalized for the removal of an impacted third molar. 根据口腔外科医生的说法, hospitalization was medically necessary because the procedure is more difficult on an older patient and because the proximity of the tooth to the mandibular nerve required that the patient be totally immobilized, which can only be accomplished in a controlled hospital environment under general anesthesia. The 雇主 denied the 员工’s request for prior approval for the hospital and anesthesia charges associated with the dental procedure.

在术前体检之后, 该雇员配偶的阻生牙已于2月23日在医院取出, 1990. 在5月30日给雇主保险公司的信中, 1990, the physician who did the pre-operative physical stated that the 员工’s spouse had intra-operative problems that necessitated the anesthesia. The 雇主 has denied payment under the 雇主 Benefit Plan for the anesthesia and hospital charges related to the extraction of the 员工’s spouse s impacted tooth.

争端

Is the 雇主 required to provide benefits under the 雇主 Benefit Plan for the anesthesia and hospital charges associated with the extraction of the 员工’s spouse’s impacted tooth?

双方立场

受托人解决争议意见. 88-340页2

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 tooth extraction because it was medically necessary for the procedure to be performed in a hospital setting under general anesthesia due to the patient’s age and the close proximity of the tooth to the mandibular nerve which required that she be totally immobilized.

Position of the 雇主: The 雇主 is not required to provide benefits under the 雇主 Benefit Plan for the anesthesia and hospital charges associated with the 员工’s spouse’s dental procedure because the removal of an impacted third molar is not among the limited types of oral surgery covered under the Plan, it was not performed as part of the treatment for a medical condition that is otherwise covered under the Plan, and there is no evidence that hospitalization for the procedure was necessary due to a preexisting medical condition.

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 pre-existing medical condition and prior approval is received from the Plan Administrator.

讨论

根据第三条. A. (1)(g)雇主福利计划, hospital benefits are 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.

In this case, the 员工’s spouse was hospitalized for’ the removal of an impacted third molar. The oral surgeon has not indicated that the 员工’s spouse had an underlying medical condition that influenced his decision to use general anesthesia in a hospital setting. The patient’s age and the proximity of the impacted tooth to the mandibular nerve may have made the dental procedure more complicated or difficult, but neither of those factors constitutes a pre- existing medical condition that required the tooth extraction to be performed in a hospital setting. 因此，不为住院费用提供福利.

受托人解决争议意见. 88-340页

Q&81-16(附副本)规定，医生服务, including anesthesia services 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 pre-existing medical condition or (2) the services are provided for treatment of a medical condition for which benefits are otherwise provided. 如上所述, there is no indication that the 员工’s spouse’s hospitalization was necessitated by a pre-existing medical condition. There is also no indication that the dental procedure was related to the treatment of any otherwise covered medical condition. 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 hospital charges resulting from the 员工’s spouse’s oral surgery on February 23, 1990.