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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: 84-381——1987年9月30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 orthodontic treatment under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s 12-year-old son was examined by an orthodontist in March 1986 and was found to have a skeletal and dental malocclusion as well as severe maxillary and mandibular crowding of his teeth. The orthodontist recommended treatment with braces, but the 员工 decided against the application of braces. 1986年5月, the 员工’s son was in an accident and suffered the loss of his maxillary central incisors. The two avulsed teeth were reimplanted and splinted in place, and the 员工’s son was referred to an endodontist for continuing treatment of the reimplanted teeth. Then, in July 1986, the orthodontist applied braces to the 员工’s son. The 雇主 paid benefits for the reimplantation and splinting of the avulsed teeth and for the endodontist’s services, but denied health benefits coverage for the braces.

争端

Is the 雇主 responsible for the provision of health benefits coverage for the 员工’s son’s orthodontic treatment?

双方立场

Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the 员工’s son because his accident destabilized his teeth to the point that braces were necessary.

Position of the 雇主: The 雇主 is not responsible for the 员工’s son’s orthodontic treatment because it constitutes dental services which are not covered under the 雇主 Benefit Plan. Since the deed for braces was established prior to the accident, and since braces are not appropriate treatment for avulsed teeth, the orthodontic treatment is not covered under 第三条A. 1984年计划(3)(e).

相关的规定

第三条A. (3)(e) of the 1984 雇主 Benefit Plan states:

(e) 口腔外科

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:

颌骨肿瘤(上颌骨和下颌骨)
Fractures of the jaw, including reduction and wiring
面骨骨折
Frenulectomy when related only to ankyloglossia (tongue tie)
颞下颌关节功能障碍, only when medically necessary and related to an oral orthopedic problem
口腔活组织检查
牙科服务 required as the direct result of an accident

第三条. A. (11) (a) of the 1984 雇主 Benefit Plan states in part:

(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.

讨论

根据第三条的规定. A. (3)(e), dental services may qualify as covered benefits when they are required as the direct result of an accident. 牙科服务 are otherwise excluded under 第三条. A. (11)(a)19, except when performed as part of treatment for an illness or injury, pursuant to C&A 81-15(附副本) . Orthodontics is a branch of dentistry which uses mechanical devices (e.g., braces) to prevent and correct irregularly positioned teeth and malocclusion. 正畸治疗是, 因此, a dental service and benefits are not provided under the 雇主 Benefit Plan, except either when required as the direct result of an accident or when performed as part of a treatment for an illness or injury which is otherwise a covered benefit.

The endodontist treating the 员工’s son stated that braces were not required to reimplant and stabilize the two avulsed teeth, but that braces may be indicated to reposition the two teeth once they stabilize. The orthodontist stated that the 员工’s son needed braces before the accident, but that the results of the accident complicated the orthodontic treatment. A Funds physician consultant reviewed the case and concluded that the orthodontic treatment was not required as a result of the accident. 此外, 医疗顾问总结道, 基于可用的文档, that it has not been established that any portion of the 员工’s son s orthodontic treatment could be attributed to the medically necessary treatment of the avulsed and reimplanted teeth. Because the need for braces was established before the accident, and because the accident resulted only in two avulsed teeth, the reimplantation of which has been covered by the 雇主, the orthodontic treatment provided constitutes dental services which are not covered under the Plan.

受托人的意见

The 雇主 is not responsible for providing health benefits coverage for the 员工’s son’s orthodontic treatment.