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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-573 – February 24, 1988
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’s spouse is 5′ 4″ tall and weighs 207 1/2 pounds. The Employee contends that his spouse’s excessive weight is a contributing factor in her hospitalizations for the treatment of blood clots and phlebitis. The Employee’s spouse’s physician recommended a professionally-supervised weight loss plan, which includes nutritional information, behavioral counseling, diet instruction, vitamin supplements and food products. The Employer denied health benefits coverage for the weight-loss program because the Employee’s spouse does not meet the criteria for morbid obesity, as stated in Article III. A. (11)(a) 25. of the Employer Benefit Plan.
Dispute
Is the Employer responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s obesity?
Positions of the Parties
Position of the Employee: The Employer is responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s obesity because the excessive weight aggravates her medical condition.
Position of the Employer: The Employer is not responsible for the provision of health benefits coverage for the treatment of the Employee’s spouse’s obesity because the Employee’s spouse’s condition does not meet the requirements for coverage under the Plan.
Pertinent Provisions
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.
Discussion
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. According to the 1983 Metropolitan Insurance Companies’ Height and Weight Tables, the desirable weight for a female who is 5’4″ tall ranges from 114 pounds to 151 pounds, depending on her frame size. The physician supervising the Employee’s spouse’s weight loss program stated that the Employee’s spouse’s goal weight is 142 pounds. Based on the above-cited tables, the Employee’s spouse’s present weight does not meet the requirements of the Employer Benefit Plan’s definition of pathological, morbid, severe obesity. Therefore, treatment of the Employee’s spouse’s obesity through a weight-loss program is not covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not responsible for the provision of health benefits coverage for a weight-loss program for the Employee’s spouse’s obesity.