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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-254——1987年1月14日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长，受托人. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

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 雇主 Benefit Plan.

背景事实

The 员工’s daughter was 5′ 5″ tall and weighed 232 pounds on July 11, 1985, when she was in her seventeenth year. Her physician has stated that the 雇主’s daughter suffered from morbid obesity and that her ideal weight was 130 pounds. Her physician performed a vertical banded gastroplasty on the 员工’s daughter on August 8, 1985. The 雇主 denied authorization for health benefits coverage for the procedure.

争端

Is the 雇主 responsible for the provision of health benefits coverage for the surgical treatment of the 员工’s daughter’s obesity?

各方立场

Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the surgical treatment of the 员工’s daughter’s obesity because the surgery was necessary and proper for treating her morbid obesity.

Position of the 雇主: The 雇主 is not responsible for the provision of health benefits coverage for the surgical treatment of the 员工’s daughter’s obesity because the 员工’s daughter’s condition does not meet the requirements for coverage provided in the Plan.

相关的规定

第三条.A. (11)(a) 25. of the 雇主 Benefit Plan states:

(11) 一般的除外

(a) 除了 to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

25. Charges for treatment of obesity, 除了病态的, morbid forms of severe obesity (200% or more of desirable weight) when prior approval is obtained from the Plan Administrator.

Q&81-20州:

主题: Surgical Treatment of Obesity
引用: 修改1950 & 1974年福利计划 & Trusts, 第三条, Sections A (3)(f) and A (11)(a) 25.

问题:

What conditions must be satisfied for the Plan Administrator to approve gastric or intestinal bypass surgery for the treatment of obesity?

答:

Benefits are only provided for these two surgical procedures when all of the following conditions are satisfied:

1. The Beneficiary has a pathological, morbid form of severe obesity (two or more times the desirable weight);

2. other, more conservative therapies have been tried and proved unsuccessful; and

3. prior approval has been obtained from the Plan Administrator.

讨论

第三条. A. (11)(a) 25. of the 雇主 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.

The physician stated that the desired weight for the 员工’s daughter at the time of her operation was 130 pounds. She would have had to weigh 260 pounds at the time of the operation to meet the 雇主 Benefit Plan’s definition of a pathological morbid form of severe obesity.

除了, the 员工 sought prior approval for his daughter’s surgery on July 11, 1985 and coverage was denied by the 雇主 on September 18, 1985. The 员工’s daughter went ahead and had the surgery on August 5, 1985, without prior approval.

受托人的意见

The 雇主 is not responsible for the provision of health benefits coverage for the surgical treatment of the 员工’s daughter’s obesity. 受托人会注意到, 然而, that the length of time between the 员工’s request for prior approval and the 雇主’s response seems unduly long.