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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-444 – November 13, 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 benefits for the treatment of obesity under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse is 5’2″ tall and weighs 198 pounds. Her physicians have stated that she has arthritis, depression, severe reflux esophagitis and urinary incontinence, all exacerbated by obesity. Several physicians have recommended weight loss, and the Employee’s spouse reports that one physician has recommended participation in a weight loss program which involves the use of a liquid nutrient (Medifast) diet.
The Employee’s spouse states that some time ago she had contacted the Employer’s previous claims administrator and was advised that treatment for obesity is covered for persons who are 65% over their ideal weight. She claims that after the Employer changed claims administrators, the new administrator advised her that treatment for obesity was not covered.
The Employer states its previous claims administrator has no record of any Inquiry from the Employee’s spouse concerning treatment for obesity. The Employer has denied the Employee’s spouse’s requests for prior approval for participation in a weight loss program.
Dispute
Is the Employer required to provide health benefits for the Employee’s spouse’s diet program?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s diet program because it was recommended by her physician as medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s diet program because the spouse does not have a pathological, morbid form of severe obesity, as required for coverage under the Employer Benefit Plan, and the medical necessity of such treatment has not been established.
Pertinent Provisions
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
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 female who is 5’2″ tall ranges from 108 to 143, depending on her frame size. Based on the above-cited tables, the Employee’s spouse’s weight would have to be 216 pounds at a minimum to meet the requirements of Article III. A. (11)(a) 25. Thus, the Employee’s spouse s weight of 198+ pounds, as stated by her physician on July 29, 1991, does not meet the Plan’s definition of severe obesity. Therefore, the Employer is not required to provide health benefits for the Employee’s spouse’s diet program.
Although the Employee’s spouse alleges that she had previously contacted the Employer’s claims administrator and was advised that treatment for obesity could be covered if she was 165% of her ideal weight, no documentation was submitted to support this allegation. The Employer states that the claims administrator has no record of such contact with the Employee’s spouse. Moreover, there is no indication that such inquiry was intended to be a request for prior approval or that prior approval was received.
Opinion of the Trustees
The Employer is not required to provide health benefits for the Employee’s spouse’s diet program.