受托人的意见
争议的解决
情况下没有. 88-125
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
88-125——1989年8月11日
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.
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 coverage for oral surgery under the terms of the 雇主 Benefit Plan.
背景事实
An orthodontist diagnosed the 员工’s dependent son as having a significant dentofacial deformity – mandibular retrognathism (a receding jaw). The 员工’s son has had orthodontic therapy to correctly align his teeth in preparation for surgery to reposition his lower jaw; bilateral sagittal split osteotomies of the mandible have been recommended. The 员工’s request for prior approval for the proposed oral surgery was denied by the 雇主. The 员工 contends that coverage should be provided for the oral surgery because his son will develop severe problems without it.
The 雇主 contends that bilateral sagittal split osteotomies are not among the covered procedures listed in 第三条. A. (3)(e) of the 雇主 Benefit Plan and that the medical information provided does not indicate a preexisting medical condition which would satisfy the requirements of 第三条. A. (1)(g)计划. The 雇主 therefore maintains that coverage for the proposed oral surgery and related hospitalization was properly denied.
争端
Is the 雇主 responsible for providing health benefits coverage for the 员工’s son’s proposed oral surgery and the related hospitalization?
双方立场
受托人解决争议意见. 88-125
第二页
Position of the 员工: The 雇主 is responsible for providing health benefits coverage for the 员工’s son’s proposed oral surgery because such – surgery is necessary to prevent problems that may develop because of the misalignment of his jaws and teeth.
Position of the 雇主: The 雇主 is not responsible for providing health benefits for the 员工’s son’s proposed oral surgery because it is not one of the covered oral surgical procedures under 第三条. A. (3)(e). The 雇主 is not responsible for providing health benefits coverage for the related hospitalization charges because a preexisting medical condition has not been documented as required under 第三条. A. (1)(g)雇主福利计划.
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
Frenulectomy when related only to ankyloglossia (tongue tie) Temporomandibular Joint Dysfunction, 只有在医学上
口腔的活组织检查
受托人解决争议意见. 88-125
第3页
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. A Funds’ medical consultant has reviewed the information submitted in this case and advised that the proposed oral surgical procedure is not among those procedures covered under 第三条. A. (3)(e). The consultant has also advised that the proposed surgery is orthodontic in nature in that it is intended to correct an overbite. 根据Q&A 81-15(附副本), 某些其他牙科和口腔外科手术, 包括“口腔正畸学,” may be 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 medical consultant has advised that the documentation provided does not establish that the proposed surgery is medically necessary to treat an otherwise covered medical condition.
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). Inpatient hospital benefits are also provided 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 medical consultant has advised that there is no evidence of a preexisting medical condition.
Since the patient’s proposed oral surgery is not one of the covered oral surgical procedures listed in 第三条. A. (3)(e)或疾病或伤害治疗的一部分，否则属于承保福利, 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, the patient’s proposed hospitalization does not meet the requirements for coverage under 第三条. A. (1)(g).
受托人的意见
The 雇主 is not responsible for providing health benefits coverage for the 员工’s son’s proposed oral surgery and hospitalization.