______________________________________________________________________________
OPINION OF TRUSTEES
______________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-247 – December 10, 1986
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for the treatment of obesity under the terms of the Employer Benefit Plan.
Background Facts
The Employee is 42 years old, 5’11” tall and weighs 278 pounds. Two physicians have stated that his excessive weight aggravates several of his medical conditions including hypertension, a degenerative vertebral disc and degenerative arthritis of the legs and knees. After attempts at a variety of diet plans were unsuccessful, the Employee’s consulting physician recommended surgical intervention consisting of a vertical banded gastroplasty to control the obesity. The Employer denied authorization for health benefits coverage of the procedure.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s obesity?
Position of the Parties
Position of the Complainant: The Employer is responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s obesity because the excessive weight aggravates several medical conditions.
Position of the Respondent: The Employer is not responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s obesity because the Employee’s condition does not meet the requirements for coverage provided in the Plan.
Pertinent Provisions
Article III. A. (11) (a) 28 of the Employer Benefit Plan states:
(11) General Exclusions
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
25. Charges for treatment of obesity, except for pathological, morbid forms of severe obesity (200% or more of desirable weight) when prior approval is obtained from the Plan Administrator.
Q&A 81-20 states:
Subject: Surgical Treatment of Obesity
References: Amended 1980 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (f) and A (11) (a) 25
Question:
What conditions must be satisfied for the Plan Administrator to approve gastric or intestinal bypass surgery for the treatment of obesity?
Answer:
Benefits are only provided for these two surgical procedures when all of the following conditions are satisfied:
1. The Beneficiary has a pathological, morbid form of severe obesity (two or more times the desirable weight);
2. other, more conservative therapies have been tried and proved unsuccessful; and
3. prior approval has been obtained from the Plan Administrator.
Discussion
Article III. A. (11) (a) 28 of the Employer Benefit Plan excludes coverage for the treatment of obesity unless the beneficiary has a pathological, morbid form of severe obesity, which is defined as 200% or more of desirable weight. According to the 1983 Metropolitan Insurance Companies Height and Weight Tables, the desirable weight for a male who is 5’11” tall ranges from 146 to 184 pounds, depending on his frame size. The Employee’s physician estimates that the ideal body weight for the Employee in this case would be 150 to 168 pounds. Based on the above-cited Tables, the Employee’s weight would have to be 292 pounds at a minimum to meet the requirements of the Employer Benefit Plan’s definition of a pathological, morbid form of severe obesity. Thus the Employee’s weight of 275 pounds does not meet the Plan’s definition of morbid obesity. Therefore, even though several complicating medical conditions exist for the Employee, treatment of the Employee’s obesity by vertical banded gastroplasty cannot be covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s obesity.