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OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

养老金领取者
雇主
88-436——1991年11月20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 benefits for inpatient hospitalization for oral surgery under the terms of the 雇主 Benefit Plan.

背景事实

The 养老金领取者’s spouse was seen by an oral surgeon because of difficulty In chewing and functioning with a mandibular (lower jaw) denture. The surgeon diagnosed severe mandibular atrophy and undertook a two-stage correction. 在第一阶段, the mandible was reconstructed with synthetic bone graft substitute in the oral surgeon’s office in February 1990. 这个程序的收费是没有争议的. 4月24日, 1990, the patient was hospitalized for the second-stage procedure which consisted of a mandibular vestibuloplasty (soft tissue connection) with skin grafting and lowering of the floor of the mouth. The oral surgeon’s charges for this second procedure are not in dispute. 然而, the 养老金领取者 contends that the hospitalization costs should be covered under the 雇主 Benefit Plan.

The 雇主 has denied benefits for the hospitalization costs incurred in connection with the second-stage surgical procedures.

争端

Is the 雇主 required to provide benefits for the 养老金领取者’s spouse’s hospitalization for oral surgery performed on April 24, 1990?

双方立场

Position of the 养老金领取者: Thee 雇主 is required to provide benefits for the 养老金领取者’s spouse’s hospitalization for oral surgery because it was medically necessary.

Opinion of Trustees Resolution of 争端 Case No. 88-436页

Position of the 雇主: The 雇主 is not required to provide benefits for the hospitalization for oral surgery because the surgery performed is not one of the covered oral surgical procedures listed under 第三条. A. (3)(e)雇主福利计划.

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)雇主福利计划 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)
Fractures of the jaw, including reduction and wiring Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, 只有在医学上

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

Dental services required as the direct result of an accident

Opinion of Trustees Resolution of 争端 Case No. 第3页

讨论

第三条. A. (1)(g) of the 雇主 Benefit Plan provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in 第三条. A. (3)(e). Benefits are also provided when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and prior approval has been received from the Plan Administrator. 例如, 先前存在的疾病，比如心脏病, 高血压, 糖尿病, or chronic obstructive pulmonary disease (COPD) may put a beneficiary at significant risk of developing complications that could result in additional injury, damage or loss if the non- covered dental services were performed in a less controlled environment. A Funds’ medical consultant has reviewed this case and advised that the mandibular vestibuloplasty with skin grafting is not among the covered oral surgical procedures listed under 第三条. A. (3)(e). 的资金’ medical consultant has also advised that there is no evidence of a pre-existing medical condition that would have required hospitalization for the performance of the procedures in this case.

Inasmuch as the oral surgical procedures performed on April 24, 1990 are not among the covered oral surgical procedures listed in 第三条. A. (3)(e) and there is no evidence of a pre-existing medical condition which necessitated hospitalization for the surgery, the 养老金领取者’s spouse’s hospitalization does not meet the requirements for coverage under 第三条. A. (1)(g).

受托人的意见

The 雇主 is not required to provide benefits under the 雇主 Benefit Plan for the 养老金领取者’s spouse’s hospitalization for oral surgery.