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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: 93-091 - 2000年3月17日
受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，唐纳德·E. 皮尔斯,小. 和
艾略特一. 西格尔.
The Trustees have reviewed the facts 和 circumstances of this dispute concerning the provision of benefits for oral surgery under the terms of the 雇主 Benefit Plan.
背景事实
3月28日, 1997, 在一个面部手术中心, the 员工 had bone grafts from his hip implanted to augment his maxilla which was severely atrophied. 9月5日, 1997, he received four dental implants which are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Coverage for these procedures was reviewed under the 雇主’s dental plan.
The 员工 claims that coverage for his oral surgical procedures should be covered as a medical procedure not as a dental procedure because during surgery it was found that his sinus walls were extremely thin 和 a small pathologic fracture was present.
争端
Is the 雇主 required to provide medical benefits coverage for the 员工’s oral surgical procedure 和 dental implants?
双方立场
Position of the 员工: The 雇主 is required to provide medical benefits for the 员工’s oral surgery 和 dental implants because of the critical condition of his sinus.
Position of the 雇主: The 雇主 is not required to provide medical benefits for the services provided because they are covered under the dental plan 和 are not among the procedures covered under 第三条A. (3) (e) of the 雇主 Benefit Plan.
相关的规定
第三条. A. (3) (e) of the 雇主 Benefit Plan states:
第三条福利待遇
A. 健康的好处
(3) Physicians’ Services 和 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 和 m和ible)
Fractures of the jaw, including reduction 和 wiring
Fractures of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporom和ibular Joint Dysfunction, only when
medically necessary 和 related to an oral orthopedic problem
口腔活组织检查
牙科服务 required as a direct result of an accident
第三条A. (7) (a) 1. of the 雇主 Benefit Plan states, in pertinent part:
(7) 其他好处
(a) Orthopedic 和 Prosthetic Devices
Benefits are provided for orthopedic 和 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. of the 雇主 Benefit Plan states:
(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
第三条. A. (3)(e) of the 雇主 Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. 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 the medical evidence submitted 和 advised that the basic procedure performed was an oral surgical procedure 和 is not among the oral surgical procedures covered under 第三条. A. (3)(e) of the 雇主 Benefit Plan. The medical consultant has further stated that based on the documentation submitted, any surgical work in relation to the sinus problems or fracture was minor 和 incidental compared to the overall bone augmentation of the maxilla 和 subsequent dental implants. 因此, the 雇主 is not required to provide benefits under the 雇主 Benefit Plan for the oral surgical procedure or the dental implants.
受托人的意见
The 雇主 is not required to provide health benefits under the 雇主 Benefit Plan for the 员工’s oral surgical procedure or dental implants.