July 25, 1983
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 81-212
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 benefits under the Employer’s Benefit Plan for the treatment of obesity.
Under Article III. A. (11)(a) 25. of your Employer’s Benefit Plan, and Question and Answer #81-20, benefits are not provided for charges for treatment of obesity except for pathological, morbid forms of severe obesity (200% or more of desirable weight), when other more conservative therapies have been tried and proven unsuccessful, and when prior approval is obtained from the Plan Administrator. In addition, under Article III. A. (3)(f) of your Employer’s Benefit Plan, benefits are not provided for gastric bypass for obesity without the prior approval of the Plan Administrator.
According to information submitted, you were 226 pounds when you were referred for treatment and your desirable weight is in the range of 109-125 pounds. Although there is a question as to whether you met the requirements for a morbid form of severe obesity, it is not necessary to address this issue because you did not receive the prior approval of your Plan Administrator as required under Article III. A. (3)(f) and III. A. (11)(a) 25. of your Employer’s Benefit Plan. Therefore, your Employer is not responsible for providing coverage for the treatment of your obesity.
Sincerely,
Harrison Combs, Chairman