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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: 88-413 - 1991年11月20日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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 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 physician has stated that she is 5’6″ tall and weighs 265 pounds, that she has been overweight all her life and has attempted to lose weight through Weight Watchers, Overeaters匿名, 饮食和针灸都没有成功. He reports that she has a family history of diabetes, 她会感到呼吸急促, 膝盖和脚部疼痛, 静脉曲张和失眠. 医生建议做胃旁路手术.

The 雇主 refused to grant prior approval for the gastric bypass because the 员工’s spouse is not over 200% of her desirable weight (130 to 144 pounds). The 雇主 states that she is morbidly obese; however, there is inadequate evidence to show that other methods of weight reduction have failed and there is no evidence of medical conditions which are aggravated by the 员工’s spouse’s excess weight and which would make the proposed surgery medically necessary.

争端

Is the 雇主 required to provide coverage for the 员工’s spouse’s proposed gastric bypass?

双方立场

Position of the 员工: The 雇主 Is required to provide coverage for the 员工’s spouse’s gastric bypass because the requirements for coverage for this procedure under the 雇主 Benefit Plan have been met.

Position of the 雇主: The 雇主 is not required to provide coverage for the 员工’s spouse’s gastric bypass because she is not over 200% of her desirable weight, there is no evidence that other methods of medical treatment of weight loss have failed, and the medical necessity for this procedure has not been established.

相关的规定

The Introduction to 第三条 of the 雇主 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, 或计划另有规定. The fact that a procedure or level of care is prescribed by a physician does not mean that it 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) 除了 to the specific exclusions otherwise contained In the Plan, 以下情况也不提供福利:

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.

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. 根据第三条. A. (11) (a) 25. of the Plan and consistent with the Trustees’ decision in ROD 84-633 (copy enclosed herein), coverage is not provided for surgical treatment of obesity unless the beneficiary has a pathological, morbid form of severe obesity (200% or more of desirable weight), has tried other more conservative therapies which proved unsuccessful, and has obtained prior approval from the Plan Administrator.

The 员工’s spouse’s physician has stated that her desirable weight is 130 pounds. 除了, the 1983 Metropolitan Insurance Company’s Height and Weight Tables give the desirable weight range of 130 to 144 pounds for a female who is 5’6″ tall and of medium frame. 根据表格, the 员工’s spouse’s weight would have to be 260 pounds at a minimum to meet the Plan’s definition of severe obesity. Thus, the 员工’s spouse’s weight of 265 pounds meets that definition.

A Funds’ medical consultant reviewed this case and advised that while the 员工’s spouse may be over 200% of her ideal body weight and may satisfy the Plan definition of severe obesity, there is inadequate medical documentation to show that more conservative measures for weight loss have been tried in earnest and that such measures proved unsuccessful. The consultant advised that there Is also no documentation of associated physical or medical problems related to the patient’s obesity that would make surgery medically necessary. It is the consultant’s opinion that the medical necessity of a gastric bypass operation for this patient has not been established. Because the medical necessity of the proposed surgery has not been established, the 雇主’s denial of prior approval in this instance Is reasonable.

受托人的意见

The 雇主 is not required to provide coverage for the 员工’s spouse’s proposed gastric bypass.