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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-700 – August 5, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for a weight loss program under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse is 5’7″ tall and weighs 211 pounds. Her psychiatrist has stated that the Employee’s spouse is taking several medications that have the side effect of causing weight gain. He further states that she has continuing pain from previous back surgery that has been intensified by the weight gain. The psychiatrist has recommended that the Employee’s spouse lose weight under a supervised program with monitoring by a medical doctor. An orthopedic surgeon and the patient’s physical therapist have also stated that excessive weight is causing extra strain on the Employee’s spouse’s back and that a weight loss program is medically necessary. The orthopedic surgeon further states that a weight loss program may prevent further surgical intervention.
The Employee’s spouse requested prior approval for a weight loss program from the Employer but was denied benefits because she does not meet the coverage criteria for the treatment of obesity, under the Employer Benefit Plan, that the Beneficiary be 200% or more over normal body weight.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s weight loss program?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s weight loss program because she must reduce her weight to prevent further complications to her health.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s weight loss program because she is not 200% or more over normal body weight as required under the Employer Benefit Plan.
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 5’7″ tall ranges from 123 to 163 pounds, depending on her frame size. Based on the above-cited Tables, the Employee’s spouse’s weight would have to be 246 pounds at a minimum to meet the Employer Benefit Plan’s definition of a pathological form of obesity.
An orthopedic surgeon has stated that there is a possibility that weight reduction may prevent further back surgery for the Employee’s spouse. This possibility does not change the strictly limited coverage criteria under the Employer Benefit Plan. Thus, the Employer is not required to provide benefits for the Employee’s spouse’s weight loss program.
Opinion of the Trustees
The Employer is not required to provide benefits for the Employee’s spouse’s weight loss program.