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OPINION OF TRUSTEES ____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

Trustees:

In Re

Employee
Employer
02-041 - 2007年6月27日

Micheal W. Buckner, A. 弗兰克·邓纳姆，迈克尔·H. Holland和Elliot A. Segal.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.

背景事实

Around March 1999, the Complainant’s spouse underwent chemotherapy for breast cancer. 1999年7月，她接受了乳房肿瘤切除术，随后接受了放疗和更多的化疗. 她的治疗在2000年1月左右结束. 癌症没有复发.

在放疗和化疗之后, the Complainant’s spouse had and continues to have dental work performed by her dentist at his office, 包括牙根管, crowns, 牙龈移植和桥接工作. 根据申诉人牙医的陈述, the chemotherapy and radiation treatments performed on the Complainant’s spouse caused the deterioration of her teeth. 申诉人要求报销这些牙科服务的费用.

The Respondent denied charges for her dental work under the Employer Benefit Plan.

Dispute
Is the Respondent required to provide coverage for dental services for the Complainant’s spouse?

双方立场

Position of the Complainant: The Respondent is required to provide coverage for the dental services for the Complainant’s spouse because the damage to her teeth is due to the radiation and chemotherapy treatments. 在接受治疗之前，她的牙齿没有任何损伤. Also, the Complainant’s son had sinus surgery that resulted in the extraction of three teeth and the placement of a bridge. 在这种情况下, the Complainant states that the Respondent provided coverage for the son’s dental work. The Complainant claims that this situation serves as precedent for covering his spouse’s dental work.

受托人的意见，ROD个案编号. 02-041 Page 2

Finally, the Complainant claims the Respondent stated that if one medical problem causes another medical problem, the second problem will be considered a covered benefit under the Employer’s Benefit Plan. 这是申诉人的立场, 在他儿子和他妻子的案子中, that one medical problem caused another problem resulting in the need for dental work.

Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s spouse’s dental work because Article III A (3)(e) of the Employer Benefit Plan, excludes dental procedures except for certain oral surgery procedures related to accidents and tumors in the mouth. 申诉人配偶的癌症并不在她的嘴里, therefore, 医疗计划的承保范围被拒绝. 牙科治疗的费用是根据答辩人的牙科治疗计划支付的. 金属杆88-323,81-363,105,81-664,112,Q&81-16和93-102支持被告的立场.

Concerning the coverage for the Complainant’s son’s dental work under the employer Benefit Plan, the Respondent states that the payment was made in error and was outside the scope of the benefit plan. Furthermore, 被告所声称的陈述, “If one medical problem causes another medical problem it will be considered a covered benefit under the medical plan,没有出现在医疗福利计划中.

有关规定. 2002年雇主福利计划第(1)(g)条规定:

第三条福利待遇

A. 健康的好处
(1)住院医疗福利

(g)口腔外科/牙科手术

Benefits are provided for a Beneficiary who is admitted to a hospital for the oral surgical procedures described in subsection (3)(e) provided hospitalization is medically necessary.

Benefits are also provided for a Beneficiary admitted to a hospital for dental procedures only if hospitalization is necessary due to a pre-existing medical condition and prior approval is received from the Plan Administrator.

受托人的意见，ROD个案编号. 02-041 Page 3

Article III A. 2002年雇主福利计划第(3)(e)段述明:

第三条福利待遇

A. 健康的好处
(3)医生服务和其他初级保健

(e)口腔外科
牙科服务不提供福利. However, 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, 只有在医学上必要且与口腔整形问题有关的情况下.

口腔活组织检查
因事故直接导致需要牙科服务

Article III A. (11) (a) 19. 2002年雇主福利计划的规定:

第三条福利待遇

A. 健康的好处
(11)一般除外条款

(a)除了《皇冠搏彩中心网站》中另有规定的具体除外事项之外, 以下情况也不提供福利:

19. 牙科服务.

受托人的意见，ROD个案编号. 02-041 Page 4

Discussion

Article III A. (1) (g) of the 2002 Employer Benefit Plan provides hospital benefits for covered oral surgery and for noncovered oral surgery admissions when pre-existing medical conditions make hospitalization medically necessary. Article III A.(3) (e) limits covered oral surgery to those procedures that are specifically listed. Article III A. (11) (a) 19. 不包括牙科服务.

The Funds’ Medical Director reviewed the documentation submitted and found that the dental services the Complainant’s spouse received were not the result of an illness or cancer of her head or mouth that required treatments of surgery, 化疗或放疗. The Medical Director noted that although the Employer Benefit Plan under Article III A. (3) (e) provides medical coverage for dental procedures during the treatment of a medical illness (including cancer) of the head and mouth (including facial sinuses), Article III A. (3) (e) does not provide coverage for dental procedures during the treatment of an illness or cancer involving other parts of the body. The Medical Director concluded that the dental services received by the Complainant’s spouse are not a covered benefit under Article III A (3) (e)雇主福利计划.

The Complainant argues that coverage should be provided for his spouse’s dental services because his son’s dental services were covered by the Respondent’s Employer Benefit Plan. However, disputes concerning coverage for dental services under the Employer Benefit Plan are reviewed on a case-by-case basis because each case must be evaluated on its own merits based on the evidence submitted.

受托人的意见

符合第三条A款. (3) (e)雇主福利计划, the Respondent is not required to provide coverage for the dental services provided to the Complainant’s spouse.