受托人的意见
争议的解决
情况下没有. 84-418
第1页 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
投诉人:被投诉人:ROD案件编号:
在再保险
员工
雇主
84-418——1987年12月2日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,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 for oral surgery under the terms of the 雇主 Benefit Plan.
背景事实
雇员的配偶因上颌骨和下颌骨明显萎缩而去看牙科医生. He performed maxillary ridge augmentation and inserted mandibular endosseous implants to halt the atrophy and to buttress the remaining bone. According to the dental surgeon, such procedures are usually performed in an outpatient facility. 然而, in this case the 员工’s spouse’s physician recommended that the oral surgery be performed in a hospital because of her history of heart disease with arrhythmias. The 员工’s spouse says that she made several attempts to obtain prior approval but was unable to contact the Plan Administrator.
The 雇主’s records do not indicate any contact from either the 员工’s spouse or her dental surgeon until September 1986, 在1986年6月住院三个月后. The 雇主 denied payment for the inpatient charges related to the oral surgical procedures because prior approval was not requested from the Plan Administrator. The 雇主 also states that it has administered the dental benefits in accordance with Article XX-A of the Dental Plan and is not responsible for any additional reimbursement for these charges.
争端
Is the 雇主 responsible for the provision of health benefits coverage for the professional fees and the hospitalization charges for the 员工’s spouse’s oral surgery?
双方立场
受托人解决争议意见. 84-418
第二页
Position of the 员工: The 雇主 is responsible for the provision of health benefits under the 雇主 Benefit Plan for the professional fees and the hospitalization charges for the 员工’s spouse’s oral surgery.
Position of the 雇主: The 雇主 is not responsible for the provision of health benefits under the 雇主 Benefit Plan for the professional fees for the 员工’s spouse’s oral surgery because benefits were administered in accordance with the provisions of the Dental Plan. The 雇主 is not responsible for the provision of health benefits for the related hospitalization charges because prior approval was not obtained from the Plan Administrator.
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. 雇主福利计划(3)(e)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)
颌骨骨折，包括面部骨复位和线状骨折
系带切除术仅与强直性咬合(舌结)颞下颌关节功能障碍有关, 只有在医学上
口腔的活组织检查
因事故直接导致需要牙科服务
受托人解决争议意见. 84-418
第3页
第三条. A. (11)(a) 19. 雇主福利计划规定:(11)一般除外事项
(a)除了《官方网站》中另有规定的具体除外事项之外, 以下情况也不提供福利:
19. 牙科服务. 讨论
第三条. A. (11)(a) 19. of the 雇主 Benefit Plan specifically excludes coverage for dental services except in very limited circumstances.
第三条. A. (3)(e)雇主福利计划 specifies the limited oral surgical procedures for which benefits are provided. A Funds medical consultant has reviewed the information submitted by the oral surgeon and has advised that the dental surgery performed on the 员工’s spouse is not among the limited procedures covered by 第三条. A. (3)(e). Because the 员工’s spouse’s dental surgery is not one of the oral surgical procedures specified in 第三条. A. 雇主福利计划的(3)(e)项，不在雇主福利计划范围内.
第三条. A. (1)(g)雇主福利计划 provides benefits for a medically necessary hospitalization when the admission is for an oral surgical procedure listed in 第三条. A. (3)(e). 第三条还规定了住院津贴. A. (1)(g) of the Plan when hospitalization for a dental procedure is necessary due to a beneficiary’s preexisting medical condition and when prior approval has been received from the Plan Administrator.
The 雇主 has established procedures for the referral of a Beneficiary’s request for prior approval in the event that a particular individual is unavailable. While the 员工’s spouse claims that she made numerous attempts to contact two benefits counselors to request prior approval, 她无法提供这种企图的任何文件或其他证据. 除了, neither the 雇主 nor the insurance carrier have any record of contacts from either the 员工’s spouse or the oral surgeon until after the surgery was performed. Inasmuch as the 员工’s spouse’s oral surgery is not among the procedures covered under 第三条. A. (3)(e)雇主福利计划, 事先未得到计划管理人的批准, 患者的住院治疗不符合第三条规定的保险要求. A. (1)(g)雇主福利计划.
受托人的意见
The 雇主 is not responsible for providing health benefits under the 雇主 Benefit Plan for the 员工’s spouse’s oral surgery or for payment of the related hospitalization charges.