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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-290 – August 21, 1991
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 the treatment of obesity under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s son is of medium frame and is 5 feet 9-1/2 inches tall. According to the information provided in this case, he was 18 years old and weighed 294 pounds when his physician requested prior authorization from the Employer’s insurance carrier for medications (Ionomin and Fastin) prescribed for weight loss. The physician has stated that the Employee’s son’s excess weight has caused low back pain and ankle weakness and that weight loss would relieve his problems. The Employer has denied benefits for the prescribed medications.
Dispute
Is the Employer required to provide benefits for the medications prescribed for treatment of the Employee’s son’s obesity?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s son’s medications for weight loss because they were prescribed by a physician to relieve medical problems caused by excess weight.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s son’s medications for weight loss because the Employee’s son does not have a pathological, morbid form of severe obesity, as required for coverage under the Employer Benefit Plan.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
Article III – Benefits
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (11) (a) 25. of the Employer Benefit Plan provides:
(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
The Introduction to Article III of the Employer Benefit Plan provides that covered services shall be limited to services which are reasonable and necessary for the diagnosis or treatment of an illness or injury. The Introduction further states that the fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. 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 between 5 feet 9 inches and 5 feet 10 inches tall and of medium frame ranges from 148 to 163 pounds. Based on the above-cited Tables, the Employee’s son’s minimum weight would have to be 296 pounds to meet the Employer Benefit Plan’s definition of a pathological morbid form of severe obesity. The Employee’s son’s weight of 294 does not quite meet the minimum requirement. However, the Tables are formulated on populations of men and women ages 25-59 and may not be applicable to younger persons, such as the Employee’s son in this case.
A Funds’ medical consultant has reviewed the information submitted in this case. The consultant has advised that, while the patient’s weight appears to be within a few pounds of the Plan’s definition of severe obesity, there is no medical documentation of conditions or complications which makes treatment for obesity medically necessary. The consultant has stated that there is also no documentation of a medical treatment plan for weight loss, other than the prescribing of Ionomin and Fastin. The consultant advises that these drugs have effects similar to amphetamines, are recommended for only short-term (a few weeks) use as adjuncts to a weight-reduction diet, and require close monitoring for side effects and possible drug dependence. According to the consultant, the use of these drugs without further documentation of a treatment protocol would not be considered a safe and effective treatment for obesity. The consultant concluded that the drugs prescribed for the Employee’s son are not medically reasonable and necessary for the treatment of a pathological, morbid form of severe obesity. Therefore, the medications prescribed for the Employee’s son’s weight loss are not covered benefits under the provisions of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for medications prescribed for the Employee’s son’s weight loss.