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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: 81-385- 1984年3月26日
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.
Pursuant to Article IX of the United Mine Workers of America 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 coverage of dental services under the 雇主’s Benefit Plan and hereby render their opinion on the matter.
背景事实
The 员工 was injured in a motorcycle accident on October 1, 1983, in which he sustained fractured ribs, chipped teeth and lacerations of his face and leg. He was admitted to the hospital following emergency room evaluation and treatment. and was discharged on October 5, 1983. The 雇主 has provided coverage for this care, but has denied authorization for payment of charges for dental treatment to repair the 员工’s chipped teeth.
争端
Is the 雇主 responsible for payment of charges for the restoration of the 员工’s teeth required as a result of the injuries sustained in the October 1, 1983年摩托车事故?
各方立场
Position of the 员工: The 员工’s representative contends that the charges for the restorative dental services should be covered because they were the direct result of the motorcycle accident.
Position of the 雇主: The Plan Administrator’s denial of coverage for restorative dental services is correct since the 雇主’s Benefit Plan Specifically excludes coverage of dental services.
相关的规定
第三条A. (3) (e) of the 雇主’s Benefit Plan states:
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
Biopsy of lesions of the oral cavity
第三条A. (11) (a) 19. of the 雇主’s Benefit Plan provides:
(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.
V&A #81-15规定:
主题: Dental and Oral Surgical Services
Reference:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Section A (3) (e)
其他:1981年合同Q&A #81-16
问题:
Are the following dental ana oral surgical procedures covered under the Plan:
a. 拔牙?
b. gingevectomy, alveolectomy, operculectomy?
c. gingivoplasty, alveoplasty, vestibuloplasty?
d. 治疗牙齿脓肿?
e. resection of prognathic mandible?
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 fracture jaw.
Except as provided in the above paragraph, none of these seven procedures is covered under the Plan.
讨论
根据第三条A款. (3) (e)和第三条A款. (11) (a) 19. of the 雇主’s Benefit Plan, dental services are specifically excluded as a covered service. 问下&A #81-15, certain dental and oral surgical procedures are covered, but only 当在医院进行时 as part of treatment for an illness or injury which is a covered benefit.
The specific services in dispute in this case are those related to restorative dental procedures. Because these services were not part of the emergency treatment of the traumatic injuries and are not an otherwise covered benefit, they are excluded from coverage by the 雇主’s Benefit Plan.
受托人的意见
The 雇主 is not responsible for payment for the restorative dental services the 员工 requires as a result of his October 1, 1983年摩托车事故.