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Compliance February 2, 2005
Court: Plan Adm. Correct in Denying Dental Benefits for Denture Implants
February 2, 2005 (PLANSPONSOR.com) - A health and
dental plan administrator who refused to pay over $100,000
for dental surgery did not act incorrectly, a federal court
has ruled.
Reported by Kip McDaniel
>US District Judge Petrese Tucker of the US District Court for the Eastern District of Pennsylvania ruled that Independent Blue Cross, the health and dental plan administrator for Patricia Roberts, did not unfairly refuse to pay for over $100,000 in dental surgery.
>In 2001, Roberts, who suffered from pemphigus vulgaris – a systemic disease that usually brings on blistering and ulceration of mucous membranes and skin – had surgery to receive dental implants after her teeth fell out. Of the total cost, Independent offered to pay only $1,055, informing Roberts that her employer’s plan did not cover such procedures.
>Roberts appealed to the administrator, who again denied to pay the costs, saying that the plan documents stated clearly that no benefits would be given for services having to do with care, filling, removal or replacement of teeth, nor with the treatment of injuries or disease of the teeth or gum structure supporting teeth.
>In court, Tucker ruled that the language was clear, and that is should be obvious to any plan participant that this service was not included in the plan. She rejected Roberts’s assertion that this was a medical problem being solved with a dental solution.
>The ruling in the case is available here .