Opinion of the Trustees
ROD Case No. 175
第1页 ______________________________________________________________________________

对受托人的看法 ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

在再保险

Employee’s Spouse Insurance Company
175, September 28, 1982

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

根据美国联合煤矿工人1950年福利计划和信托皇冠搏彩中心网站第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了有关胃绕道手术争议的事实和情况，并在此提出他们对此事的意见.

Background Facts

该雇员的配偶在一名医生的照顾下治疗肥胖症. She is 5 feet, 6 1/2 inches tall and weighed 235 pounds. 据她的医生说，她有长期的肥胖问题，但她自己通过饮食控制的努力并没有起作用, working with physicians, Weight Watchers, 等. In addition, she has the probability of gallbladder disease. 她入院接受择期胃旁路手术治疗肥胖.

该员工的配偶声称，她曾两次通过电话联系保险公司，询问是否会为她的胃旁路手术付款. 她两次都说，她被告知，只要对她的健康有必要，就会提供津贴, and that all she needed was a letter from her 医生tor to that effect. The Insurance Carrier does not maintain copies of phone inquiries after six months; therefore, they have no record of the calls. 保险公司声明他们的员工在合同语言方面受过良好的培训，因此他们有理由相信他们的员工会正确地解释要求.

Question or Dispute
雇主是否负责治疗肥胖的胃分流手术的福利?

Position of Parties

申诉人:胃绕道手术的费用应该支付，因为保险公司在电话中告诉她，只要对她的健康有必要，就会提供手术，她所需要的只是医生的一封信.

他们没有和病人的电话通话记录. They base their denial on Q&A #38, 哪条规定除非受益人的体重达到理想体重的200%或以上，否则不能为治疗肥胖提供福利.

Pertinent Provisions
Article III. A. (3)(f) of the Employer’s Benefit Plan provides as follows:

(f) Surgical Services Limitations

未经计划管理者事先批准，某些外科手术不提供福利. 此类外科手术包括但不限于以下内容:

Plastic surgery, including mammoplasty Reduction mammoplasty
Intestinal bypass for obesity
Gastric bypass for obesity

Cerebellar implants
Dorsal stimulator implants
Prosthesis for cleft palate if not covered by crippled

children services Organ transplants

Article III. A. (3)(h) of the Employer’s Benefit Plan provides as follows:

“福利是为受益人在家中提供的服务提供的, 在诊所或医生的办公室里治疗疾病或受伤, if provided by a physician.

1978 Contract Question and Answer #38 provides as follows:
Subject: Obesity
Reference: Amended 1950 & 1974 Benefit Plans & Trusts, Art. III, Sect. A (3) (f) (h) Question:

1. a) Under Art. III, Sect. A (3) (h)津贴仅限于"治疗疾病或受伤"的服务, if provided by a physician”. 在这种情况下，是肥胖的治疗，没有其他病理存在(如.g., hypertension, cardiovascular disease, diabetes), a covered benefit?

Opinion of the Trustees ROD Case No. 175
第3页

b)

Answer: 1. a)

b)

在什么条件下提供手术治疗肥胖的好处?

是的，如果诊断是病理性的，病态的严重肥胖，那么.e., 200% or more of desirable weight. 在治疗开始时有资格获得肥胖津贴的受益人在达到理想体重之前也有资格获得这种津贴.

除非满足下列所有条件，否则不提供肥胖手术治疗的福利:

1. 1)受益人符合上述肥胖定义;
2. 2)  other, more conservative therapies have been tried and proven unsuccessful; and
3. 3)  authorization has been obtained from the Plan Administrator. Discussion

Under Article III. A. (3) (h)在雇主计划中，由医生提供治疗疾病的福利. However, under Q&A #38, where no other pathology exists, 只有在诊断为病态的情况下，肥胖的治疗才包括在内, morbid form of severe obesity, where the patient’s weight is 200% or more of her desirable weight, and prior approval has been received from the Plan Administrator. 因为雇员的配偶在接受胃旁路手术时体重为235磅，而她的理想体重是130磅, 她不符合病态严重肥胖的要求(她的体重没有达到理想体重的200%或更多). 因此，雇主不负责胃旁路手术的费用.

In addition, 关于电话请求事先授权的事实存在争议. 雇员的配偶声称，保险公司表示，如果手术对她的健康是必要的，并且如果她向他们提供了她的医生的信，他们将提供保险. 保险公司表示，他们不会提供这些信息，但会就正确的要求向她提出建议. 然而，运营商没有保留超过六个月的通话记录. 因为劳工部授予受托人的豁免只允许受托人解决有关福利性质的争议或雇主计划条款下的资格问题, the Trustees may not address this issue. It should be noted that under the terms of the Employer’s Plan, 必须事先获得计划管理人而非保险公司的授权.

Opinion of the Trustees

The Trustees are of the opinion that, under the terms of the Employer’s Benefit Plan, 雇主不负责支付对雇员配偶进行胃绕道手术的费用.