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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 88-489 - 1992年10月28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年福利计划和信托, 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 a disabled 员工 under the terms of the 雇主 Benefit Plan.

背景事实

10月18日, 1990, the 员工’s spouse consulted a dental surgeon for the evaluation and treatment of severe facial swelling. The patient was scheduled for surgery on October 31, 1990. 牙科医生拔了五颗脓牙, performed an enucleation of an enlarged maxillary cyst, 活检以排除恶性肿瘤, and an immediate reconstruction of the left maxillary defect with bone graft material. The biopsy confirmed a pre-operative diagnosis of a large odontogenic cyst of the left maxilla. The 员工 has stated that the company administrator gave prior approval for the procedure.

The 雇主 provided benefits for the dental services up to the scheduled amounts payable under its Dental Plan, and denied medical benefits under the 雇主 Benefit Plan for the remaining charges on the grounds that the services were dental services, and not covered by the 雇主’s Medical Benefit Plan.

争端

Is the 雇主 required to provide benefits under the 雇主 Benefit Plan for charges related to the 员工’s spouse’s oral surgery on October 31, 1990?

双方立场

Position of the 员工: 雇主是 required to provide benefits under the 雇主 Benefit Plan because the company administrator approved the surgical procedure, 医生证明手术是, 事实上, 医疗程序.

Position of the 雇主: 雇主是 not required to provide benefits because the dental services performed are not covered under the 雇主’s Medical Benefit Plan and the Plan Administrator did not give prior approval for the procedure.
相关的规定

第三条. A. 雇主福利计划第(3)(e)条规定:

(3) 医生服务和其他初级保健

(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:

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. (11)有关部分19个国家;

(11) 一般的除外

19. 牙科服务

讨论

根据第三条. A. (3)(e)雇主福利计划, benefits are provided for a limited number of oral surgical procedures, 包括颌骨的肿瘤. Although the patient asserts she was initially given the diagnosis “tumor of the jaw,” the pre- and post-operative record indicates a diagnosis of a maxillary cyst and multiple abscessed teeth.

A Funds’ medical consultant has reviewed the operative report and states that, 在他看来, the report indicates that the maxillary cyst was contiguous with the most posterior of the five abscessed teeth, and that the procedure was clearly done to treat the obviously abscessed teeth and not to evaluate and treat a potentially malignant tumor of the maxilla. 一个囊肿, 在《皇冠搏彩中心网站》中的定义是“囊”, 正常或异常, 含有液体或半固体物质.

The pre- and post-operative diagnosis contained in the operative report was “left maxillary odontogenic cyst”. 因为这显然是个囊肿, 而不是下巴的肿瘤, it would not be covered under the 雇主 Benefit Plan. The Plan is specific about the inclusion of procedures for tumors of the jaw, (maxilla and mandible). 一个肿瘤, 在Dorland也有定义, is “a mass of new tissue which persists and grows independently of its surrounding structures, 也没有生理上的作用". The consultant concludes that the procedure performed was dental in nature and clearly not one of the oral surgical procedures covered by 第三条. A. (3)(e)雇主福利计划. 除了, the consultant found no evidence in the record of a pre-existing medical illness or condition requiring hospitalization which might provide coverage under 第三条. A. (1)(g), and dental services are excluded under 第三条. A. (11)雇主福利计划第19条.

第三条. A. (3)(e)雇主福利计划 provides benefits for biopsies of the oral cavity. 根据收到的记录, a biopsy was performed by the hospital on the removed cyst and the cystic fluid. 雇主是 required to provide benefits for any charges from the hospital in connection with the actual biopsy of the cyst, 第三条规定的. A. (3)(e)雇主福利计划.

The issue of prior approval has been raised by both sides; 然而, the Plan does not require prior approval for covered oral surgical procedures. 因此, the Trustees conclude that since the surgical services were not medical in nature, 如第三条所述. A. (3)(e)雇主福利计划, the 雇主 is not required to provide benefits for the hospital charges, and the surgeon and anesthesiology charges in relation to the oral surgery performed on October 31, 1990.

受托人的意见

雇主是 not required to provide benefits for hospital, anesthesia or surgical charges in relation to the 员工 s spouse’s oral surgery on October 31, 1990. 雇主是, 然而, required to provide benefits for the biopsy of the oral cavity 第三条规定的. A. (3)(e).