Opinion ID: 452971
Heading Depth: 1
Heading Rank: 2

Heading: The Relevant Plan Provisions

Text: 6 The employer and the UMWA are signatories to the National Bituminous Coal Wage Agreement of 1981 (1981 Wage Agreement), a multi-employer collective bargaining agreement, the successor to a 1978 Wage Agreement. According to an unrebutted affidavit of a member of the Benefits Committee for the Bituminous Coal Operators' Association (BCOA), the 1978 Wage Agreement provided for the first time for the establishment and maintenance of employee benefit plans by the signatory operators rather than the trustees to provide health and other non-pension benefits to their employees. The affidavit also avers that in establishing the employee benefit plans to be maintained and implemented by the signatory operators, BCOA and UMWA negotiators reviewed all of the interpretations that had previously been established and utilized by the Trustees and, in the course of explicit, informed and intense bargaining, adopted, revised or rejected those interpretations. What was finally agreed upon in negotiations was then inserted into the employee benefit plans to be maintained and implemented by the signatory operators. 7 Pursuant to the provisions of the applicable collective bargaining agreement, the employer maintained a benefit plan to provide health care benefits for employees and eligible dependents, including spouses. One of the health care benefits included within the plan was coverage of certain surgical treatments for morbid forms of severe obesity (two or more times desirable body weight). The plan sets out two prerequisites to obtaining benefits: 8 1. The beneficiary has a pathological, morbid form of severe obesity (200% or more of desirable weight); 9 2. Prior approval has been obtained from the Plan Administrator. 10 (emphasis added). The affidavit referred to above specifically states that the prior approval eligibility requirement was discussed and adopted as part of the benefit plan as a result of collective bargaining between the BCOA and UMWA during negotiation of the 1978 Wage Agreement. That eligibility requirement has been carried forward in employee benefit plans of signatory operators since 1978. 11 The trustees are given authority to make alterations in the benefit plan provisions, as they may deem to be necessary or appropriate, only upon prior written approval by the Employers and the Union. They are also authorized and directed, after adequate notice and consultation with the employers and union, to make changes in the plans if necessary to conform the terms of the plan to the requirements of ERISA, or any other applicable federal law, and the regulations issued thereunder and to comply with all applicable court or government decisions or rulings. 12 In rejecting Mrs. Zayac's appeal of the plan administrator's denial of her claim for benefits, the trustees stated: 13 Question and Answer 81-20, attached hereto, lists three conditions that must be satisfied for benefits to be provided for surgical treatment of obesity: (1) the diagnosis signifies a pathological, morbid form of severe obesity, (2) other, more conservative therapies have been tried and proved unsuccessful, and (3) prior approval has been obtained from the Plan Administrator. 14 Although the Employee's spouse meets the first two requirements, she did not obtain prior approval from the Plan Administrator. Because prior approval of the Plan Administrator had not been obtained, as required, the Employer is not responsible for payment of charges incurred by the Employee. 15 The trustees had issued two Question and Answer interpretations on coverage for obesity treatment before Mrs. Zayac's surgery. In 1979, they issued Contract Question and Answer No. 38, as follows: Subject: Obesity Question: 16 1. a) Under Article III, Section A(3)(h) the benefits are limited to services for treatment of illnesses or injuries, if provided by a physician. In this context, is the treatment of obesity, where no other pathology exists (e.g., hypertension, cardiovascular disease, diabetes), a covered benefit? 17 b) Under what conditions are benefits provided for the surgical treatment of obesity? Answer: 18 1. a) Yes, if the diagnosis signifies pathological, morbid form of severe obesity, i.e., 200% or more of the desirable weight. Beneficiaries eligible for obesity benefits at the onset of treatment are eligible for such benefits until they reach their desirable weight. 19 b) Benefits are not provided for surgical treatment of obesity unless all of the following conditions are met: 20 1) The beneficiary's condition meets the above definition of obesity; 21 2) other, more conservative therapies have been tried and proven unsuccessful; and 22 3) authorization has been obtained from the Plan Administrator. 23 In 1981, the trustees issued Question and Answer No. 81-20, which provided as follows: Subject: Surgical Treatment of Obesity 24 References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A(3)(f) and A(11)(a)25 2 Question: 25 What conditions must be satisfied for the Plan Administrator to approve gastric or intestinal bypass surgery for the treatment of obesity? Answer: 26 Benefits are only provided for these two surgical procedures when all of the following conditions are satisfied: 27 1. The Beneficiary has a pathological, morbid form of severe obesity (two or more times the desirable weight); 28 2. other, more conservative therapies have been tried and proved unsuccessful; and 29 3. prior approval has been obtained from the Plan Administrator.