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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 Case No: 88-764 – 1993年12月15日
董事会:Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. 华莱士,受托人.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for oral surgical procedures under the terms of the Employer Benefit Plan.
背景事实
8月18日, 1992, the Employee’s daughter had her four wisdom teeth removed by an oral surgeon in his office while she was under intravenous sedation. The oral surgeon stated that the teeth were impacted in such positions that, 他们进来的时候, they would not be in a position that would benefit the patient. The oral surgeon additionally stated that these teeth would eventually develop cysts and cause infection and pain. He stated that he chose to removed the four teeth before any problems developed.
The Employer paid benefits under its dental plan, and denied benefits under the medical plan. The Employee states that because the four teeth were considered full boney impactions, benefits should be available under the medical portion 计划的详情.
争端
Is the Employer required to provide medical benefits for the removal of the Employee’s daughter’s four impacted wisdom teeth on August 18, 1992?
双方立场
Position of the Employee: The Employer is required to provide medical plan benefits for the removal of his daughter’s four wisdom teeth because the teeth were considered to be full boney impactions and therefore, eligible for benefits under the medical portion 计划的详情.
Position of the Employer: The Employer is not required to provide medical benefits for the removal of the Employee’s daughter’s four wisdom teeth because they are not among the limited oral surgical procedures provided for in 第三条.A.(3)(e).
相关的规定
(3) Physicians’ Services and Other Primary Care
(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:
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)
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 a direct result of an accident
第三条.A.(11)(a) 19. 状态:
(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
第三条. A.(3)(e) of the Employer Benefit Plan provides benefits for a limited number of covered oral surgical procedures. 第三条. A. (11)(a) 19. excludes coverage for dental services.
The oral surgeon stated that the Employee’s daughter’s wisdom teeth were such in a position that they would never benefit her, and that the removal was performed to avoid potential future infection and pain. 四颗智齿(1, 16, 17, and 32) were removed in the oral surgeon’s office under intravenous sedation.
The Employer provided benefits for the procedures under the dental portion of its Plan. The Employee states that because the four wisdom teeth were considered full boney impactions, that they should be considered under the medical portion of the Employer’s benefit plan.
In ROD 88-697 (copy attached) a Funds’ medical consultant concluded that the extraction of wisdom teeth is not among the limited covered oral surgical procedures listed in 第三条. A. (3)(e) of Plan, and are specifically excluded under 第三条.A.(11)(a) 19. 计划的详情. Because the services rendered to the Employee’s daughter do not fall within the Employer Benefit Plan’s limited coverage for oral surgical procedures, the Trustees conclude that the Employer is not required to provide benefits for the removal of the Employee’s daughter’s wisdom teeth on August 18, 1992.
进一步, although the Employee has raised the issue of dental plan coverage for the services provided to his daughter, this is not an issue that may be addressed in a Resolution of 争端. The opinion of the Trustees is concerned solely with whether the services in question fall within the limits of oral surgical procedures covered under the Employer Benefit Plan.
受托人的意见
The Employer is not required to provide benefits under the Employer Benefit Plan for the Employee’s daughter’s oral surgery on August 18, 1992.