Obese Truck Driver Loses Gastric Surgery Coverage Ruling

October 29, 2004 (PLANSPONSOR.com) - An obese participant in a union-run health plan lost another legal fight in his battle to get health-care coverage for his gastric bypass surgery when a federal appeals court upheld a lower court ruling agreeing with the plan's coverage denial.

The US 7 th Circuit Court of Appeals ruled that the Central States, Southeast and Southwest Areas Pension and Health and Welfare Funds was reasonable when plan trustees turned down a coverage request from plaintiff Terry Manny for the obesity surgery.

According to the court, Manny, a 58-year-old truck driver weighing 470 pounds suffered from a variety of health problems including diabetes, high blood pressure, joint pain, respiratory problems, swelling of the legs and feet, lower back pain, and depression. US District Judge Charles Norgle Sr., of the US District Court for the Northern District of Illinois, upheld the plan’s denial on the grounds it fell under an exclusion for cosmetic procedures, noting that the trustees had authority to interpret the plan’s provisions.

The appeals court agreed. “The trustees based their decision on an interpretation of the plan as excluding coverage for all such operations rather than a judgment that Manny’s motivation was cosmetic rather than health,” Circuit Judge Richard Posner wrote for the court. “Indeed, for all we know, they were acting in Manny’s best interests. The surgery that he wants is dangerous, and of uncertain value. His medical problems, though undoubtedly aggravated his obesity, are (most of them anyway), treatable without surgery. But we are wandering from the issue, which is simply the reasonableness of the trustees’ interpretation of the plan; it was reasonable so our hands are tied.”

The case, Manny v. Cent. States, Southeast and Southwest Areas Pension and Health and Welfare Funds, is at  http://www.ca7.uscourts.gov/op3.fwx?submit1=showop&caseno=04-1797.PDF .