November 1, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-134
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed your Request for Advisory Opinion concerning coverage of a gastric bypass, gastrojejustomy and raux-en-y for the Employee’s spouse under the terms of the Employer Benefit Plan.
Question and Answer 81-20, attached hereto, lists three conditions that must be satisfied for benefits to be provided for surgical treatment of obesity: (1) the diagnosis signifies a pathological, morbid form of severe obesity, (2) other, more conservative therapies have been tried and proved unsuccessful, and (3) prior approval has been obtained from the Plan Administrator.
Although the Employee’s spouse meets the first two requirements, she did not obtain prior approval from the Plan Administrator. Because prior approval of the Plan Administrator had not be obtained, as required, the Employer is not responsible for payment of charges incurred by the Employee.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
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Paul R. Dean, Trustee