October 1, 1985
(Opinion issued in letter form; name and address deleted)
Re: Opinion of Trustees
Resolution of Dispute
Case No. 84-071
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 benefits under the Employer Benefit Plan for the treatment of your wife’s obesity.
According to Article III A. (11)(a) 25 of your Employer Benefit Plan, benefits are not provided for charges relative to the treatment of obesity except for pathological, morbid forms of severe obesity (200 percent or more of desirable weight) and when prior approval is obtained from the Plan Administrator.
The treatment of your wife’s obesity would consist of a surgical procedure known as a vertical banded gastroplasty. According to the information you submitted, your wife weighs between 195 and 210 pounds and her height ranges between 5′ 1″ and 5′ 2″. The two physicians who supplied information in support of your wife’s claim failed to agree on her weight; the weight of 195 pounds was provided by your wife.
Height and weight tables published most recently in 1983 by The Metropolitan Life Insurance Company were developed as a public service to provide people with sound guidelines for weight control. According to those tables, the weight range for a woman with a height of 5′ 1″ and a small frame is from 106 to 118 pounds. Your wife would have to weigh a minimum of 212 pounds before she would meet the requirements for being considered morbidly obese.
Since your wife does not satisfy the requirements to be considered morbidly obese, the conditions for coverage of charges for the treatment of obesity established in Article III A. (11)(a) 25 of the Employer Benefit Plan have not been satisfied. Therefore, your Employer is not required to grant prior approval of coverage for the treatment you seek for your spouse’s obesity.
Joseph P. Connors, Sr., Chairman
Paul R. Dean, Trustee
William B. Jordan, Trustee
William Miller, Trustee
Donald E. Pierce, Jr., Trustee