______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-573 – 1988年2月24日

Board of Trustees: 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 coverage for the treatment of obesity under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse is 5′ 4″ tall and weighs 207 1/2 pounds. The 员工 contends that his spouse’s excessive weight is a contributing factor in her hospitalizations for the treatment of blood clots and phlebitis. The 员工’s spouse’s physician recommended a professionally-supervised weight loss plan, which includes nutritional information, 行为心理咨询, 饮食指导, vitamin supplements and food products. The 雇主 denied health benefits coverage for the weight-loss program because the 员工’s spouse does not meet the criteria for 病态的 obesity, 如第三条所述. A. (11)(a) 25. of the 雇主 Benefit Plan.

争端

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

双方立场

Position of the 员工: The 雇主 is responsible for the provision of health benefits coverage for the treatment of the 员工’s spouse’s obesity because the excessive weight aggravates her medical condition.

Position of the 雇主: The 雇主 is not responsible for the provision of health benefits coverage for the treatment of the 员工’s spouse’s obesity because the 员工’s spouse’s condition does not meet the requirements for coverage under 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) 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, 除了病态的, 病态的 forms of 严重肥胖 (200% or more of desirable weight) when prior approval is 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, 病态的 form of 严重肥胖, which is defined as 200% or more of desirable weight. According to the 1983 Metropolitan Insurance Companies’ Height and Weight Tables, the desirable weight for a female who is 5’4″ tall ranges from 114 pounds to 151 pounds, depending on her frame size. The physician supervising the 员工’s spouse’s weight loss program stated that the 员工’s spouse’s goal weight is 142 pounds. Based on the above-cited tables, the 员工’s spouse’s present weight does not meet the requirements of the 雇主 Benefit Plan’s definition of pathological, 病态的, 严重肥胖. 因此, treatment of the 员工’s spouse’s obesity through a weight-loss program is not covered under the 雇主 Benefit Plan.

受托人的意见

The 雇主 is not responsible for the provision of health benefits coverage for a weight-loss program for the 员工’s spouse’s obesity.