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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: 88-541 - 1992年7月15日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. 西格尔,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 oral surgery under the terms of the 雇主 Benefit Plan.

背景事实

1990年9月, an oral surgeon diagnosed the 员工’s spouse as having lesions of her right uvula and left external oblique ramus ridge (areas of the right tonsil and left upper jaw). Noting his concern that the lesions might be cancerous, the surgeon proposed an early operation. 出于不相关的原因, the spouse decided to have the rest of her upper teeth removed at the same time. 9月21日, 1990 the 员工’s spouse underwent the oral surgery, which included an excisional biopsy of the orpharynx, a frenulectomy and extractions of eight upper teeth. The procedures were done in the local hospital under a general anesthetic on an outpatient basis. 外科医生没有事先征求许可, citing a need to do the procedures as soon as possible, and noting that approval often took six to eight weeks.

The 雇主 provided benefits for all allowable surgical charges, 但拒绝支付医院的费用, 麻醉药和病理学家的费用. The 雇主 stated these procedures could have been done with equal efficacy in the oral surgeon’s office.

争端

Is the 雇主 required to provide benefits for the hospital, 麻醉 and pathology charges incurred in connection with the 员工’s spouse’s oral surgery performed on September 21, 1990?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the hospital, 麻醉 and pathology charges in connection with the 员工’s spouse’s oral surgery on September 21, 1990 because the surgeries were considered eligible expenses and the use of the hospital was medically necessary.
Position of the 雇主: The 雇主 is not required to provide benefits for the hospital, 麻醉, and pathology charges incurred by the 员工’s spouse in connection with her oral surgery on September 21, 1990, because the hospitalization and related charges were not medically necessary and could have been provided with equal efficacy at a lower level of care.

相关的规定

第三条. 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. 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:

颌骨肿瘤(上颌骨和下颌骨)
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
Dental services required as the direct result of an accident

讨论

根据第三条. A. (1)(g)计划, benefits are provided for hospitalization for dental procedures only if necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator. 举个例子, 已有的疾病，如心脏病, 高血压, diabetes or chronic obstructive pulmonary disease (COPD) could put a beneficiary at significant risk of developing complications that could result in further injury, damage or loss if the dental services (covered or non-covered) were performed in a less controlled environment. 的资金’ medical consultant has advised that there is no documentation of a pre-existing medical condition that would have necessitated hospitalization for these dental procedures. 进一步, the consultant notes that there is no medical documentation of the need to use the hospital facilities on an outpatient basis for the covered oral surgery. Therefore, the requirements for hospitalization under 第三条. A. (1)(g)不符合.

The pathological examination of the biopsy specimens is an integral component of the surgical procedure. Thus, the pathology charge would be eligible for benefits, regardless of the setting for the surgery. 类似的, 麻醉 would be necessary for the surgeon to secure the biopsy specimens, 也有资格获得福利.

受托人的意见

The 雇主 is required to provide benefits under the 雇主 Benefit Plan for the pathology charges and 麻醉 charges related to the biopsy of the oropharynx; however, the 雇主 is not required to provide benefits for the hospital charges incurred by the 员工’s spouse on September 21, 1990.