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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: 88-067 - 1989年2月14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 dental services under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse has been fitted with several different sets of dentures since 1977, but continues to experience pain and swelling of the gums. A prosthodontist has determined that the discomfort is caused by a sensitivity to the plastic denture material and has proposed construction of a new set of dentures using chrome cobalt metal bases.
The 员工’s spouse’s physician has stated that the long standing problem with her dentures seems to aggravate her hypertension. In his opinion, correction of the problem with her dentures may alleviate her high blood pressure. The 雇主 denied coverage for the proposed denture construction.
争端
Is the 雇主 required to provide health benefits for the 员工’s spouse’s dentures?
双方立场
Position of the 员工: The 雇主 is required to provide health benefits for the 员工’s spouse’s dentures under the 雇主 Benefit Plan because they are medically necessary to alleviate her hypertension.
Position of the 雇主: The 雇主 is not required to provide health benefits under the 雇主 Benefit Plan for the 员工’s spouse’s dentures because they are dental services and are specifically excluded from coverage.
相关的规定
第三条. A. (7)(a) 1. 的“雇主福利计划”规定:
(7) 其他好处
(a) 矫形和假体设备
Benefits are provided for orthopedic and prosthetic devices prescribed by a physician when medically necessary.
The following types of equipment are covered:
1. Prosthetic devices which serve as replacement for internal or external body parts, other than dental.
包括人造眼睛, 鼻子, 手(或钩), 脚, 武器, 腿和造口袋和用品.
第三条. A. (11)(a) 19. 的“雇主福利计划”规定:
(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
19. 牙科服务.
Q&81-15州:
主题: 牙科及口腔外科服务
参考资料:1950年修订 & 1974年福利计划 & 信托皇冠搏彩中心网站,
第III条A (3) (e)款
其他:1981年合同Q&A #81-16
问题:
Are the following dental and oral surgical procedures covered under the Plan:
a. 拔牙?
b. gingivectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibulopasty?
d. 治疗牙齿脓肿?
e. 下颌骨前突切除术?
f. 下颌骨钉?
g. 口腔正畸学?
答:
The dental and oral surgical procedures listed above, 当在医院进行时, 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 拔牙 during emergency treatment of extensive facial damage resulting from an auto accident; (2) the 拔牙 during treatment of cancers of the head and mouth; and (3) the insertion of a 下颌骨钉 to repair a fractured jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
讨论
第三条. A. (11)(a) 19. of the 雇主 Benefit Plan specifically excludes coverage for dental services. 此外，第三条. A. (7) (a) 1. of the Plan specifically excludes benefits for dental prosthetic devices. Q&A 81-15 states that benefits may be provided for certain dental procedures when performed in the hospital as part of the treatment for an illness or injury which is otherwise covered under the Plan.
The 员工’s spouse suffers from hypertension. Her physician has stated that her condition seems to be aggravated by her sensitivity to plastic denture material and that a new set of dentures constructed from a special material may alleviate the hypertension. A Funds’ medical consultant has reviewed the information submitted in this case and has advised that there is no documentation to support the claim that the patient’s plastic denture material is contributing to her hypertension. The consultant stated that the medical records indicate that the 员工’s spouse is receiving conventional treatment for her hypertension. The consultant further advised that the denture replacement is strictly a dental service and it is not part of the treatment of an otherwise covered illness or injury. 建议更换义齿, 因此, is not among the limited dental procedures for which benefits may be provided under the Plan, 用Q来解释&A 81-15.
受托人的意见
The 雇主 is not required to provide health benefits for the 员工’s spouse’s dentures.