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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-362 – April 30, 1987
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 for dental implants under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse has been treated by an oral surgeon for her atrophic mandibular ridge, a painful condition which prevents the successful wearing of dentures. The Employee’s spouse’s oral surgeon states that the Employee’s spouse also has bilateral internal derangement of her temporomandibular joints. The Employee’s spouse underwent dental implant surgery on November 13, 1986.
The Employer denied coverage for the surgery after the Employer’s consulting physician advised that the use of dental implants is a treatment to secure dentures. The Employee has requested coverage for the dental implant surgery.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s spouse’s dental implant surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the Employee’s spouse’s dental implants because the purpose of the treatment is to correct temporomandibular joint dysfunction.
Position of the Employer: The Employer is not responsible for the Employee’s spouse’s dental implants because they represent dental services which are not covered under the Employer Benefit Plan.
Pertinent Provisions
Article III. A. (11) (a) of the 1984 Employer Benefit Plan states in part:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. Dental services.
Article III. A. (3)(e) of the 1984 Employer Benefit Plan states:
(e) Oral Surgery
Benefits are not provided for dental services. However, 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
Fracture of the facial bones
Frenulectomy when related only to ankyloglossia (tongue tie)
Temporomandibular Joint Dysfunction, only when medically necessary and related to an oral orthopedic problem
Biopsy of the oral cavity
Dental services required as the direct result of an accident
Q&A 81-88 states:
Subject: Oral Orthopedics
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (e) and (m), and A (11) (a) 19
Question:
Are benefits provided for treatment of Temporomandibular Joint Dysfunction?
Answer:
No, except when treatment involves:
1. the use of corrective external orthopedic appliances; or
2. corrective surgery to specifically reorient the temporomandibular joint.
If either treatment is to be rendered by an oral surgeon, prior approval must be obtained from the Plan Administrator.
Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures.
Q&A 81-15 states:
Subject: Dental and Oral Surgical Services
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III. Section A (3) (3)
Other: 1981 Contract Q&A #81-16
Question:
Are the following dental and oral surgical procedure covered under the Plan:
a. extraction of teeth?
b. gingevectomy, alveolectomy, operulectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. treatment for abscessed teeth?
e. resection of prognathic mandible?
f. mandibular bone staple?
g. orthodontics?
Answer:
The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident: (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
Discussion
Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. Article III. A. (11) (a) 19. of the Employer Benefit Plan, as well as Q&A 81-15, specifically excludes coverage for dental services except in very limited circumstances. This case does not involve one of those limited circumstances.
Article III. A. (3)(e) of the Employer Benefit Plan provides benefits for certain limited oral surgical procedures; however, since the dental treatment recommended for the Employee’s spouse does not involve oral surgery for one of these limited, surgical procedures, it does not qualify for coverage under this provision. In Q&A 81-88, benefits are described for treatment of temporomandibular joint dysfunction (TMJ) when treatment involves the use of corrective external orthopedic appliances or corrective surgery to reorient the temporomandibular joint. It specifically excludes benefits for treatment of TMJ which involves the insertion of dentures. The treatment in question involves the use of dental implants and not corrective external orthopedic appliances.
Because the Employee’s spouse’s dental implant surgery was not one of the covered oral surgical procedures, was not required as the direct result of an accident, and was not one of the procedures covered for the treatment of temporomandibular joint dysfunction, but rather was associated with the insertion of dentures, it is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing health benefits under the Employer Benefit Plan for the Employee’s spouse’s dental implant treatment.