Opinion of Trustees
Resolution of Dispute
Case No. 81-612
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OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondents: ROD Case No:

In Re 81-612 – August 27, 1985

Employee Employer

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.

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 coverage for hospitalization for a dental procedure under the terms of the Employer Benefit Plan. They hereby render their opinion on the matter.

Background Facts

The Employee’s son, who is severely mentally retarded, was hospitalized on August 7, 1984 for dental services. The Employer has denied payment for the hospital and professional charges resulting from this care, although on at least one other occasion authorization for such hospitalization was granted.

Dispute

Is the Employer responsible for payment of the charges resulting from the Employee’s son’s hospitalization for dental care on August 7, 1984?

Position of the Parties

Position of the Employee: The Employer is responsible for payment of the charges resulting from the Employee’s son’s hospitalization, especially since authorization and payment for such services were granted in the past.

Opinion of Trustees Resolution of Dispute Case No. 81-612
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Position of the Employer: Coverage was denied because the Employee’s son was determined not to have a pre-existing medical condition to establish that this admission was medically necessary and because prior approval of the Plan Administrator was not granted in this case, in accordance with Article III. A. (1)(g).

Pertinent Provisions
Article III.A. (1)(g) of the Employer Benefit Plan states in relevant part:

Benefits are also provided for a beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.

Discussion

Article III. A. (1)(g) provides benefits for hospitalization for dental procedures only if such hospitalization is necessary due to a pre-existing medical condition and when prior approval has been received from the Plan Administrator. In this case, the Plan Administrator has indicated that it will waive the prior approval requirement if the Trustees determine that requirements of Article III. A. (1)(g) were satisfied.

A hospitalization for a dental procedure cannot qualify under this provision based solely on the difficulty, complexity, or extent of the dental service in and of itself; rather, it must be necessary to assure proper medical management, control or treatment of the patient in light of the underlying medical condition. A beneficiary with a history of several heart attacks who needs to have his teeth extracted may qualify for hospitalization. A beneficiary with well-controlled hypertension or diabetes, on the other hand, would normally not qualify for hospitalization.

A Funds medical consultant has reviewed the information in file regarding this dispute. It appears from the medical information supplied by the beneficiary’s physician that hospitalization in order to administer general anesthesia is required due to the beneficiary’s pre-existing medical condition. Specifically, the beneficiary is severely mentally retarded and, as a result of the mental retardation, is severely and uncontrollably hyperkinetic. These two conditions prevent the oral surgeon from performing the procedure (dental manipulation requiring complete relaxation of the patient) safely and effectively using local anesthesia. The use of a general anesthetic was therefore necessary in this case to permit the required services and to avoid harm to the patient. Under these circumstances, the pre-existing medical condition requirement of Article III. A. (1)(g) is satisfied.

Opinion of the Trustees

Opinion of Trustees Resolution of Dispute Case No. 81-612
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The Employer is responsible for the payment of charges resulting from the Employee’s dependent’s hospitalization on August 7, 1984.