受托人的意见
连杆箱编号. 168
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
1980年11月25日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 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 health coverage for gastric bypass surgery and hereby render their opinion on the matter.

背景事实

The 员工 is a mineworker eligible for health benefits under the 雇主’s Plan. 雇员的配偶, also an eligible beneficiary under the 雇主’s Plan, underwent gastric bypass surgery on February 8, 1980, 治疗病态肥胖.

According to a report in the file from the surgeon, 病人, 我36岁, 她一生中大部分时间都超重, weighed 232 pounds at the time of surgery (ideal weight – 110 lbs.), and was suffering from hypertension and depression. Further medical evidence in the file reveals that 病人 had been under treatment on diet program since as far back as 1971 without significant or lasting success.

The first recorded notice to the 雇主’s Plan covering the surgery occurred by phone call from the attending surgeon to the Insurance Carrier on March 20 1980. Subsequently, full written documentation was supplied to the Carrier by the surgeon.

争端

Is the 雇主 responsible for payment of the charges incurred by the 员工 as a result of gastric bypass surgery?

各方立场

受托人的意见
连杆箱编号. 168
第二页
员工’s Position: The 雇主 is responsible for payment of the incurred medical charges. 医疗必要性已详细说明, as was the prior history of unsuccessful weight control through other means over many years.

雇主’s Position: In accordance with Article III, Section A(3)(f) of the 雇主’s Plan and 1978 合同问&A #38, the 雇主 has denied benefits based upon the lack of evidence that

事先获得批准.

国家有关规定
o Article III, Section A (3)(f) of the 雇主’s Plan provides:

“Benefits are not provided for certain surgical services without prior approval of the Plan Administrator. Such surgical procedures include, but are not limited to, the following:

Plastic surgery, including mammoplasty Reduction mammoplasty
肥胖症的肠道旁路治疗
胃旁路术治疗肥胖

小脑植入物
背侧刺激器植入
Prosthesis for cleft palate if not covered by crippled children services Organ transplants

o 1978年合约Q&A #38指出:

主题:问题:1. a)

b)答:

1. a) b)

肥胖

根据第三条, Section A (3)(h) the benefits are limited to services “for the treatment of illnesses or injuries, 如果由医生提供.” In this context, is the treatment of obesity, where no other pathology exists (e.g., hypertension, cardiovascular disease, diabetes), a covered benefit?

Under what conditions are benefits provided for the surgical treatment of obesity?

Yes, if the diagnosis signifies pathological, morbid, form of severe obesity, i.e.， 200%或更多的理想重量. Beneficiaries eligible for obesity benefits at the onset of treatment are eligible for such benefits until they reach desirable weight,

Benefits are not provided for surgical treatment of obesity unless all of the following conditions are met:

受托人的意见书. 168
第3页

1. the beneficiary’s condition meets the above definition of obesity
2. other, more conservative therapies have been tried and proven unsuccessful; and
3. authorization has been obtained from the Plan Administrator

   讨论

合同问&A #38 lists three requirements that a beneficiary must meet in order to receive benefits for surgical treatment of obesity: (1) the diagnosis must signify a pathological form of obesity, (2) more conservative therapies must have been attempted without success, and (3) authorization must have been obtained from the Plan Administrator. Information in the form of letters and medical reports has been supplied by several physicians indicating 病人 meets the first two requirements.

As to the third requirement there is no evidence that the 雇主 was contacted prior to the surgery. 而, the first reference to a contact with the 雇主 is a letter to the attending surgeon from the Insurance Carrier confirming a telephone conversation of March 20, 1980, approximately six weeks following surgery. 这封信, 未标明日期的, describes the criteria governing surgical treatment of obesity and invites the physician to send medical documentation.

Since prior approval of the Plan Administrator had not been obtained, 根据需要, the gastric bypass surgery is not covered under the terms of the 雇主’s Plan.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for payment of charges incurred by the 员工 as a result of gastric bypass surgery.