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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-383 – August 12, 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 for gastric stapling surgery under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s wife suffers from exogenous obesity (obesity due to overeating), severe diabetes mellitus, and severe hyperlipidemia. Her physician has been unable to effectively treat either her diabetes or her hyperlipidemia. Her physician believes that in order for her to decrease the symptoms of her diabetes and hyperlipidemia, she must lose weight. The Employee’s wife has been unable to lose weight using more conventional dieting techniques; therefore, her physician has recommended that she undergo gastric stapling surgery. The Employee’s wife sought prior approval for the surgery from the Employer but was denied coverage.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the Employee’s wife’s gastric stapling surgery?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefit coverage for the Employee’s wife’s gastric stapling surgery because 1) her exogenous obesity is worsening her other health problems and 2) she is unable to lose weight using more conventional dieting techniques.
Position of the Employer: The Employer is not responsible for the Employee’s gastric stapling surgery because the Employee’s wife is not morbidly obese.
Pertinent Provisions
Article III. A. (11)(a) 25. of the 1984 Employer Benefit Plan states in part:
(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.
Discussion
Article III. A. (11)(a) 25. of the Employer Benefit Plan specifically excludes coverage for the treatment of obesity which is not morbid obesity, defined as 200% or more of desirable weight. The Employee’s wife’s physician states that the Employee’s wife is 5 feet 3 inches and weighs 210 pounds. According to Metropolitan Life Insurance Company’s 1983 Height and Weight Tables, a desirable weight for a small-framed woman of her height would be 111 – 124 pounds. The Employee’s wife’s weight would have to be at least 222 pounds to meet the criteria of Article III. A. (11)(a) 25. Therefore, she does not meet the standards for coverage under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for providing health benefits coverage for the Employee’s wife’s gastric stapling surgery.