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受托人的意见
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在再保险
原告: 养老金领取者
被申请人: 雇主
ROD案例编号: CA-069 - 2003年6月30日
受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D. 哈德逊,
艾略特一. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Coal Industry Retiree Benefit Act of 1992 (Coal Act) 雇主 Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
背景事实
The Complainant’s spouse has been diagnosed with Alzheimer’s Syndrome. To improve the Complainant’s spouse’s intake of nourishment and capacity to swallow and to speak, her oral surgeon recommended dental implants to hold the Complainant’s spouse’s lower denture in place. The Complainant’s spouse underwent dental surgery on November 12, 2001. Subsequently, the Respondent denied coverage for the surgery.
争端
Is the Respondent required to provide health benefits for the 养老金领取者’s spouse’s dental implant surgery?
双方立场
Position of the 原告: The Respondent is required to provide health benefits for the 养老金领取者’s spouse’s dental implant surgery because the procedure was medically necessary.
Position of the 被申请人: The Respondent is not required to provide benefits for the Complainant’s spouse’s dental implant surgery because dental implants are not covered under the 雇主 Benefit Plan. 此外, dental prosthetic devices and dental service are specifically excluded under the Plan.
相关的规定
第三条. A. (3)(e) of the 雇主 Benefit Plan states:
(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)
Temporomandibular Joint Dysfunction, 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. (7) (a) 1. of the 雇主 Benefit Plan states:
(7) 其他好处
(a) Orthopedic and Prosthetic Devices
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.
第三条. A. (11) (a) 19. of the 雇主 Benefit Plan states:
(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
Dental implants are utilized for the purpose of attaching replacement teeth to the gums or bones of the mouth. 第三条. A. (3)(e) of the 雇主 Benefit Plan specifies the limited oral surgical procedures for which benefits are provided. Charges for dental and oral surgical procedures may also be covered under the 雇主 Benefit Plan only when the procedures are performed in a hospital as part of the treatment for an illness or injury which is otherwise a covered benefit. (See RODs 84-362, 84-442, and 84-564.) 牙科服务 are otherwise excluded under 第三条. A. (11) (a) 19. 计划的详情. 此外，第三条. A. (7) (a) 1. 计划的详情 specifically excludes benefits for dental prosthetic devices.
A Funds’ medical consultant has reviewed this case and has advised that the implant procedure in question is not one of the limited oral surgical procedures covered under 第三条. A. (3)(e) of the Coal Act 雇主 Benefit Plan. 此外, the medical consultant notes that the Coal Act 雇主 Benefit Plan does not cover dental orthopedic and prosthetic devices.
Because the Complainant’s spouse’s dental implant surgery was not one of the covered oral surgical procedures and was not required as part of the treatment of an illness or injury that is otherwise a covered benefit, the Respondent is not required to provide coverage for the dental implants under the Coal Act 雇主 Benefit Plan.
受托人的意见
The Respondent is not required to provide coverage for the Complainant’s spouse’s dental implants under the Coal Act 雇主 Benefit Plan.