OPINION OF TRUSTEES
ROD Case No: 84-254 – January 14, 1987
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.
The Employee’s daughter was 5′ 5″ tall and weighed 232 pounds on July 11, 1985, when she was in her seventeenth year. Her physician has stated that the Employer’s daughter suffered from morbid obesity and that her ideal weight was 130 pounds. Her physician performed a vertical banded gastroplasty on the Employee’s daughter on August 8, 1985. The Employer denied authorization for health benefits coverage for the procedure.
Is the Employer responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s daughter’s obesity?
Position of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s daughter’s obesity because the surgery was necessary and proper for treating her morbid obesity.
Position of the Employer: The Employer is not responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s daughter’s obesity because the Employee’s daughter’s condition does not meet the requirements for coverage provided in the Plan.
Article III.A. (11)(a) 25. 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 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3)(f) and A (11)(a) 25.
What conditions must be satisfied for the Plan Administrator to approve gastric or intestinal bypass surgery for the treatment of obesity?
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.
Article III. A. (11)(a) 25. 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.
The physician stated that the desired weight for the Employee’s daughter at the time of her operation was 130 pounds. She would have had to weigh 260 pounds at the time of the operation to meet the Employer Benefit Plan’s definition of a pathological morbid form of severe obesity.
In addition, the Employee sought prior approval for his daughter’s surgery on July 11, 1985 and coverage was denied by the Employer on September 18, 1985. The Employee’s daughter went ahead and had the surgery on August 5, 1985, without prior approval.
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits coverage for the surgical treatment of the Employee’s daughter’s obesity. The Trustees would note, however, that the length of time between the Employee’s request for prior approval and the Employer’s response seems unduly long.