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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: 1981年11月24日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article 12 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 and hereby render their opinion on the matter.

背景事实

雇员的儿子, 16岁, was injured in an automobile accident on May 11, 1980, sustaining fractures of the mandible, 两颗门牙也断了. Emergency services provided immediately following the accident included reduction of the fractures and wiring of the jaws, which remained in place for a period of six weeks. The 雇主’s Plan covered the emergency treatment and follow-up services related to it. 保险承运人, 然而, has denied coverage of subsequent endodontic services provided by a dentist and an oral surgeon consisting of root canal surgery and x-rays related to ultimate restoration of the two front teeth.

问题或争议

Is the 雇主 responsible for payment of the charges for the endodontic services related to the restoration of the patient’s damaged front teeth?

各方立场

员工: The 员工 feels that refusal of payment by the insurance carrier for the dental restorative (endodontic) services was in error because they were the direct result of the automobile accident.

雇主: 保险承运人 bases denial of coverage for the endodontic services on Q&A #48.

相关的规定

第三条, 雇主计划A (3) (e)项 which provides as follows:

“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
“面部骨骼骨折
“Frenulectomy when related only to ankyloglossia (tongue tie)”

第三条, A (10) (a) (19) of the 雇主’s Plan which specifically lists dental services as excluded from coverage.

Q&A #48

“Subject: Dental and Oral Surgical Procedures

“引用: 1950年修订后的 & 1974年福利计划 & Trusts, 第三条, Section A (1) (g) and Section # (3) (e)

”的问题:

“Are the following dental and oral surgical procedures covered under the 1978 Agreement?

a. 拔牙?
b. gingivectomy, alveolectomy, operculectomy:
c. gingivoplasty, alveoplasty, vestibuloplasty?
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?

“回答:

“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 treatment for an auto accident involving extensive facial damage; (2) the 拔牙 during treatment for cancers of the head and mouth; or (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 1978 Agreement.

“Dental services are specifically excluded from coverage, except for those listed under the Oral Surgery benefit in Sect. A (3) (B). These include surgical treatment for:

——颌骨肿瘤
“- fractures of the jaw, including reduction and wiring
——面骨骨折
“- frenulectomy, when related to ankyloglossia (tongue tie).”

讨论

根据第三条, 雇主计划A (3) (e)项, dental services are specifically excluded as a covered service. 问下&A #48, 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 endodontic care provided on December 4, 1980年和12月18日, 1980, approximately seven months after the 员工’s son’s accident. The endodontic care included root canal therapy and x-rays preparatory to later restoration of the two previously broken teeth with porcelain crowns. Since these services were not part of the emergency treatment of the traumatic injuries, they are excluded from coverage by the 雇主’s Plan.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for payment for the endodontic services provided to the 员工’s dependent son.