受托人的意见
争议的解决
情况下没有. 84-532
第1页 ______________________________________________________________________________
对受托人的看法 ______________________________________________________________________________
在再保险
投诉人:被投诉人:ROD案件编号:
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.
根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 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 coverage for oral surgery under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse had a maxillofacial deficiency that caused dysfunctional occlusion with speech and chewing dysfunction and a many-year history of muscle pain, 与右颞下颌关节功能障碍相关的头痛和关节痛. The TMJ condition was treated conservatively with a superior repositioning splint that brought the temporomandibular joint into position. In order to correct the skeletal and occlusal dysfunction and to stabilize her temporomandibular joint so that the symptoms would not return, a dental surgeon performed a LeFort I osteotomy and ostectomy of the maxilla with superior repositioning and a bilateral transoral sagittal split osteotomy and ostectomy of the mandible with advancement. 由于手术的性质和范围，手术是在医院住院的基础上进行的.
雇主声明，有限的口腔外科手术和麻醉在雇主的牙科计划范围内. 雇主预先向牙医提供了牙科计划下应支付的牙科福利金额. The 雇主 states that this predetermination did not include prior approval for the hospitalization because the oral surgery did not treat an otherwise covered medical condition and there was no indication of a pre- existing medical condition that would justify the hospitalization as medically necessary. 雇主声明已根据牙科计划支付了口腔手术的费用.
雇主拒绝支付手术费用, 麻醉, 以及雇主福利计划下的住院费用. 雇主的立场是，这些程序不属于第三条所涵盖的程序. A. (3)(e)的雇主福利计划，因为
员工
雇主
84-532——1989年6月7日
受托人解决争议意见. 84-532
第二页
surgery did not specifically reorient the temporomandibular joint and because the 员工’s spouse was not being treated for an otherwise covered medical condition. The related hospital charges are also not covered because a preexisting medical condition has not been documented as required under 第三条. A. (1)(g)雇主福利计划.
争端
雇主是否有责任为牙科医生的费用提供健康保险, 麻醉师的费用, 以及与雇员配偶的口腔手术有关的住院费用?
双方立场
Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the 员工’s spouse’s oral surgery and hospitalization because they were medically necessary to treat her temporomandibular joint dysfunction.
Position of the 雇主: The 雇主 is not responsible for the provision of health benefits coverage under the 雇主 Benefit Plan for the 员工’s spouse’s oral surgery because it is not one of the covered oral surgical procedures listed under 第三条. A. (3)(e), 而且没有证据表明手术是治疗的一部分，否则会有保险. The 雇主 is not responsible for the provision of health benefits for the related hospitalization charges because a preexisting medical condition has not been documented as required under 第三条. A. (1)(g)计划. The 雇主 provided the 员工 and the dentist with a predetermination of the amount of dental benefits payable under the Dental Plan and has paid benefits for the oral surgery under the Dental Plan.
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.
受托人解决争议意见. 84-532
第3页
第三条. A. 雇主福利计划(3)(e)规定:(e)口腔手术
牙科服务不提供福利. 然而, 如果由牙科医生或普通外科医生进行下列有限的口腔外科手术，则享有福利:
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的讨论
第三条. A. (3)(e) of the 雇主 Benefit Plan specifies the limited oral surgical procedures for which benefits are provided under the Plan. 第三条. A. (3)(e) stipulates that oral surgical treatment for temporomandibular joint dysfunction is a covered benefit only when it is medically necessary and related to an oral orthopedic problem. Q&A 81-68 (copy enclosed herein) states that corrective surgery to specifically reorient the temporomandibular joint is a covered treatment for TMJ dysfunction. A Funds’ medical consultant has reviewed the information submitted by the dental surgeon and has advised that the procedures performed on the 员工’s spouse are not among those listed in 第三条. A. (3)(e). The consultant has advised that the surgery did not specifically reorient the temporomandibular joint; rather, 目的是矫正患者的咬合功能障碍, 正畸问题. The Trustees have addressed the question of coverage for surgery to correct a malformation of the jaw and teeth in a number of previous opinions: copies of 81-529, 81-672, 84-142, 和84-411附在这里. 受托人在这些情况下的结论是，这类手术不包括口腔外科手术.
根据Q&附81-15副本一份.)，牙科及口腔外科手术的收费，但第III条所指明的收费除外. A. (3)(e), are covered under the 雇主 Benefit Plan only when the procedure is performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. No evidence has been submitted to establish that this surgery is medically necessary to treat an otherwise covered illness or injury.
第三条. A. (1)(g)雇主福利计划 provides benefits for medically necessary hospitalization when the admission is for an oral surgical procedure listed in 第三条. A. (3)(e). 住院治疗牙科手术也提供住院津贴
受托人解决争议意见. 84-532
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是由于受益人先前存在的健康状况所必需的吗, 以及事先获得计划管理人的批准. A Funds’ medical consultant has advised that there is no evidence of a preexisting medical condition necessitating that the oral surgery be performed in a hospital.
由于雇员配偶的拟议口腔手术不属于第三条所列的口腔外科手术. A. (3)(e), 或疾病或受伤治疗的一部分，否则是一个覆盖的福利, 不包括专业服务费. 因为该手术不属于第三条所列的口腔外科手术. A. (3)(e)并且没有证据表明先前存在健康状况, 患者的住院治疗不符合第三条规定的保险要求. A. (1) (9). 因此, 雇员配偶的口腔手术或住院均不提供福利.
因为牙科福利是根据煤炭工资协议第XX-A条规定的, 受托人仅有权解决涉及第二十条规定的利益的争议, 受托人不得处理与雇主牙科计划所提供的福利有关的争议.
受托人的意见
The 雇主 is not responsible for providing health benefits under the 雇主 Benefit Plan for the professional services and hospitalization charges associated with the 员工’s spouse’s oral surgery.