mdla
11-29-2003, 11:54 PM
Masella u. Blue Cross & Blue Shield of Connecticut
United States Court of Appeals for the Second Circuit, 1991
plaintiff diagnosed in 1985 as suffering from temporo. mandibular joint dysfunction or TMJ, a painful disorder of the jaw joint. As a result, she received non-surgical treatment, including biofeedback and an orthotic, an appliance that fit on the plaintiff's teeth and was intended to reposition part of her jaw joint. When the plaintiff submitted the claims to her insurer for payment, they were rejected. This is what the courts had to say about that..................
Like the district court, we find persuasive the views of Masella's experts that Masella's treatment for TMJ principally related to the jaw joint rather than the teeth. We recognize that neither Sorrentino, who treated Masella, nor Mark, another dentist specializing in oral and maxillofacial surgery, is necessarily entirely impartial on the question of whether Blue Cross should be required to reimburse claimants for the treatment of TMJ under the terms of policies like Masella's containing "dental" exclusions. However, their explanations of the nature and treatment of the condition known as TMJ, which are essentially unchallenged by Blue Cross, consistently and clearly describe the focus of a TMJ disorder and its treatment as a joint that happens to be connected to the teeth, not the teeth themselves. The Connecticut Society of Oral and MaxilIofacial Surgeons (the MaxiIlofacial Surgeons), appearing as amicus curiae, also describe TMJ and its treatment as focused on a disorder of the jaw rather than of the teeth, and refer us to a substantial number of state court insurance cases so holding.
United States Court of Appeals for the Second Circuit, 1991
plaintiff diagnosed in 1985 as suffering from temporo. mandibular joint dysfunction or TMJ, a painful disorder of the jaw joint. As a result, she received non-surgical treatment, including biofeedback and an orthotic, an appliance that fit on the plaintiff's teeth and was intended to reposition part of her jaw joint. When the plaintiff submitted the claims to her insurer for payment, they were rejected. This is what the courts had to say about that..................
Like the district court, we find persuasive the views of Masella's experts that Masella's treatment for TMJ principally related to the jaw joint rather than the teeth. We recognize that neither Sorrentino, who treated Masella, nor Mark, another dentist specializing in oral and maxillofacial surgery, is necessarily entirely impartial on the question of whether Blue Cross should be required to reimburse claimants for the treatment of TMJ under the terms of policies like Masella's containing "dental" exclusions. However, their explanations of the nature and treatment of the condition known as TMJ, which are essentially unchallenged by Blue Cross, consistently and clearly describe the focus of a TMJ disorder and its treatment as a joint that happens to be connected to the teeth, not the teeth themselves. The Connecticut Society of Oral and MaxilIofacial Surgeons (the MaxiIlofacial Surgeons), appearing as amicus curiae, also describe TMJ and its treatment as focused on a disorder of the jaw rather than of the teeth, and refer us to a substantial number of state court insurance cases so holding.
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