March 25, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 84-003
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 Resolution of Dispute concerning payment of charges for the treatment of your spouse’s obesity.
According to the information submitted, surgical treatment consisting of a gastric by-pass has been recommended as treatment of your spouse’s obesity. The physician who would perform this surgery has established that, as of November 23, 1984, your wife weighed 193 pounds and that her desirable weight is 115 pounds.
Under Article III A. (11) (a) 25. of your Employer’s Benefit Plan, charges for the treatment of obesity are excluded from coverage except when a pathological, morbid form of severe obesity (200% or more of desirable weight) exists and prior approval is obtained from the Plan Administrator. According to the information provided, your spouse is not 200% or more of her desirable weight. Your Plan Administrator has correctly determined that the surgical services for which you requested prior authorization are not covered benefits under the Plan.
Because your spouse is not 200% or more of her desirable weight, your Employer is not responsible for the provision of benefits for the surgical treatment of her obesity and correctly withheld prior authorization for the procedure.
Harrison Combs, Chairman
Joseph P. Brennan, Trustee
William Miller, Trustee
Paul R. Dean, Trustee