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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: 84-603——1988年4月7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, 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 for oral surgery under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse has polycystic kidney disease with progressive kidney failure and has elected to undergo kidney transplantation as an alternative to renal dialysis treatments. Her physician recommended that she have full mouth extractions of her teeth in order to prevent any potential source of infection subsequent to the transplantation. The 员工’s dentist performed the extractions on an outpatient basis from August 10, 1987年至9月14日, 1987 and fabricated and placed complete upper and lower dentures on September 14, 1987.

The 雇主 has provided dental benefits for the 员工’s dental work under its Dental Plan but denied health benefits coverage because the procedures are not among the oral surgical procedures covered under 第三条. A. (3)(e) of the 雇主 Benefit Plan and because dental procedures are otherwise covered under the 雇主 Benefit Plan only when performed in a hospital inpatient setting.

争端

Is the 雇主 responsible for providing health benefits coverage for the 员工’s spouse’s full mouth extraction of teeth?

双方立场

Position of the 员工: The 雇主 is responsible for providing health benefits coverage for the 员工’s spouse’s full mouth extraction of teeth because the procedure was medically necessary to prevent any potential source of infection subsequent to her kidney transplantation.
Position of the 雇主: The 雇主 is not responsible for providing health benefits coverage for the 员工’s spouse’s full mouth extraction of teeth because the procedure is not among the oral surgical procedures covered under 第三条. A. (3)(e) of the 雇主 Benefit Plan, and it was performed on an outpatient basis.

相关的规定

第三条. A. (3)(e) of the 雇主 Benefit Plan states:

(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 and mandible)
Fractures of the jaw, including reduction and wiring
面骨骨折
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem
口腔活组织检查
Dental services required as the result of an accident

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. Full mouth extraction of teeth is not among those procedures covered by the Plan. 根据Q&A #81-15(附件副本), certain dental and oral surgical procedures, 包括拔牙, are covered under the 雇主 Benefit Plan only when performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit.

The 员工’s spouse’s oral surgery was performed in a dentist’s office over a two-week period. Inasmuch as the 员工’s spouse’s oral surgery is not among the limited procedures covered under 第三条. A. (3)(e) and was not performed in a hospital as required pursuant to Q&A 81-15, benefits are not available under the 雇主 Benefit Plan.

Dental benefits are provided under Article XX-A of the Coal Wage Agreement. The Trustees have authority to resolve only disputes involving benefits established by Article XX. Therefore, the Trustees may not address disputes concerning Dental Plan benefits.

受托人的意见

The 雇主 is not responsible for providing health benefits coverage under the 雇主 Benefit Plan for the 员工’s spouse’s full mouth extraction of teeth.