OPINION OF TRUSTEES
ROD Case No: 88-233 – February 28, 1990
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 an Employee’s diet program under the terms of the Employer Benefit Plan.
The Employee is 5’11” tall and weighs 280 pounds. His physician has stated that his excessive weight aggravates his medical problem of degenerative joint disease with back and knee pain. The physician recommended that he enroll in the Medifast Diet Program, a physician-supervised weight-loss plan. The Employee was placed on a liquid nutrient diet for five months (May 19, 1989 to October 19, 1989) and was seen by his physician weekly for the administration of a vitamin B-12 injection and testing that consisted of blood work, an electrocardiogram and a urinalysis. The Employer has refused to provide benefits for the liquid nutrient and portions of the testing.
Is the Employer required to provide health benefits for the Employee’s diet program?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s diet program because it was medically necessary that he lose weight to relieve his medical-problems.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s diet program because the Employee does not have a pathological, morbid form of severe obesity, as required for coverage under the Employer Benefit 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.
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 Company’s 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. Based on the above-cited Tables, the Employee’s weight would have to be 292 pounds at a minimum to meet the Employer Benefit Plan’s definition of a pathological, morbid form of severe obesity. Thus, the Employee’s weight of 280 pounds does not meet the Plan’s definition of severe obesity. Therefore, even though complicating medical conditions exist for the Employee, the Employer is not required to provide benefits for the Employee’s Medifast Diet Program.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s diet program.