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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: 84-633——1988年7月12日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. 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 for gastric bypass surgery under the terms of the 雇主 Benefit Plan.
背景事实
The 员工’s spouse requested prior approval from the 雇主 for coverage of a proposed gastric bypass. The 员工’s spouse’s gynecologist stated that she is 5′ 6″ and weighs 310 lbs. and that she has attempted to lose weight through diets and exercise without success. The gynecologist reported that she has symptoms of arthritis, 临界高血压, 低血糖症, 经前综合症, 月经不规律和抑郁. The gynecologist referred her to a general surgeon who recommended a gastric bypass.
The 雇主 refused to grant prior approval for the gastric bypass because although the 员工’s spouse is morbidly obese, the medical complications which would make this type of surgery medically necessary are not present in her case.
争端
Is the 雇主 responsible for providing coverage for the 员工’s spouse’s proposed gastric bypass?
双方立场
Position of the 员工: The 雇主 is responsible for providing coverage for the 员工’s spouse’s gastric bypass because it is medically necessary.
Position of the 雇主: The 雇主 is not responsible for providing coverage for the 员工’s spouse’s gastric bypass. There is no documentation that she fulfills the criteria for pathologic obesity stipulated by the Plan, and the medical necessity of the procedure has not been established.
相关的规定
The Introduction to 第三条 of the 雇主’s Benefit Plan states in part:
Covered benefits shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that is medically reasonable or necessary or that it is covered under this Plan.
第三条. A. (11)(a) 25. 的“雇主福利计划”规定:
(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:
25. 治疗肥胖的费用, 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.
1981年合约Q&A #81-10指出:
主题: 肥胖的手术治疗
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. 受益人有病态, 严重肥胖的病态形式 (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
The Introduction to 第三条 of the 雇主 Benefit Plan states that covered services are those which are reasonable and necessary for the treatment of an illness. 第三条. A. (11) (a) 25. 和问&A #81-10 of the 雇主 Benefit Plan exclude coverage for the treatment of obesity unless the beneficiary has a pathological, 严重肥胖的病态形式, has tried other more conservative therapies which proved unsuccessful and prior approval is obtained from the Plan Administrator.
A Fund’s medical consultant reviewed the case and advised that while the 员工’s spouse is over 200% of ideal body weight and therefore satisfies the Plan definition of severe obesity, there is inadequate evidence to show that more conservative measures for weight loss have been tried in earnest and that such measures proved unsuccessful. 此外, he advises that there is insufficient proof that the 员工’s spouse has other medical complications (e.g., hypertension, diabetes mellitus, or cardiac problems) which would make surgery medically necessary. Because the requirements for coverage have not been satisfied, the 雇主’s denial of prior approval for the 员工’s spouse’s gastric bypass is reasonable.
受托人的意见
The 雇主 is not responsible for providing coverage for the 员工’s spouse’s proposed gastric bypass.