Exbom v. Central States, Southeast and Southwest Areas Health and Welfare Fund

• Decision Date: 27 April 1990
• Docket Number: No. 89-1822,89-1822
• Citation: 900 F.2d 1138
• Parties: Leilani EXBOM, Plaintiff-Appellant, v. CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Defendant-Appellee.
• Court: U.S. Court of Appeals — Seventh Circuit

Page 1138

900 F.2d 1138

Leilani EXBOM, Plaintiff-Appellant, v. CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS HEALTH AND WELFARE FUND, Defendant-Appellee.

No. 89-1822.

United States Court of Appeals Seventh Circuit.

Argued Feb. 13, 1990.

Decided April 27, 1990.

Walter D. Braud, Rock Island, Ill., for plaintiff-appellant.

Francis J. Carey, Chicago, Ill., for defendant-appellee.

Before WOOD, Jr., and COFFEY, Circuit Judges, and ESCHBACH, Senior Circuit Judge.

ESCHBACH, Senior Circuit Judge.

Leilani Exbom is morbidly obese. She has been so for most of her life. This condition does not suit her, and she has not accepted it passively. Indeed, for the last ten years she has waged a virulent campaign against it. She has made repeated attempts to reduce her weight by dieting. Dieting, however, has availed her little improvement. She has also tried to reduce her weight by surgery. In 1979 she underwent what is known as a jejunoileal bypass and subsequently lost 110 pounds. The surgery was risky, however, and in 1986, as the threat of unfortunate side effects increased, it was undone. Exbom then regained the weight she had lost.

By Spring of 1987 Exbom's obesity had created some problems. Exbom had a backache, her muscles were sore, and her limbs felt heavy. She was often tense and keyed up, and then fatigued. Her self-esteem was low, and she was self-conscious around others. She had low energy and little interest in the normal activities of life. She felt lonely, even blue. As a cure for these problems her doctor recommended a gastroplasty, or gastric stapling operation, which purportedly would reduce her ability and desire to eat. This, in turn, purportedly would lead to her long sought weight loss and an improvement in her physical condition.

Gastroplasties are expensive. Exbom wanted one, but she did not want responsibility for the bill. She sought instead to have the Central States, Southeast and Southwest Areas Health and Welfare Fund pay for the proposed operation. Central States is a Taft-Hartley Trust governed by an eight member Board of Trustees. Four of the Trustees represent the International Brotherhood of Teamsters and the other four represent the management of businesses in the trucking industry. The Trustees administer the Trust in accordance with a Trust Agreement. The Agreement authorizes the Trustees to make rules and regulations necessary to administer the Trust, to establish plans to provide benefits to certain teamsters and their families, to be the final authority in disputes about benefits, and to interpret conclusively the terms of the Agreement and the plans.

One of the plans set up by Central States is the C-6 Medical Plan. The Plan pays for health-related expenses incurred by its members, one of whom was Exbom. The Plan does not pay for these expenses willy-nilly, however. There are limitations. Two of them are important in this case.

One is the cosmetic surgery limitation. The Plan will not pay "any charge incurred for any treatment or service connected with surgery performed for cosmetic purposes ... unless the treatment service is required as a result of accidental bodily injury." The Plan Document, which is the technical constitution for the Plan, defines "cosmetic" as "[r]econstructive or plastic surgery which is provided primarily to improve the physical appearance of a Covered individual and which restores appearance but does not correct or materially relieve a medical condition." The Document provides an example of cosmetic surgery: "Surgery for obesity, including gastric bypass, gastric stapling [gastroplasty], intestinal bypass, lipectomy, suction lipectomy, and any other surgical procedure, the purpose and result of which is simply to remove adipose tissue." The Plan Booklet, which is an explanation of the Plan in less technical language, recites similar language. The other limitation is the experimental surgery limitation. The Plan will not pay "any charges [for medical treatment] which are not uniformly and professionally endorsed by the general medical community as standard medical care, including [medical treatments] which are experimental in nature." The Document defines "experimental" as charges for medical treatment "not uniformly and professionally endorsed by the general medical community as standard medical care." The Booklet again recites similar language.

In May of 1987 Exbom submitted to Central States a request for benefits on a questionnaire entitled "Predetermination of Benefits for Surgery for Obesity." This form had been brought to Exbom's attention via a Central States newsletter. The newsletter informed her that "[i]f determined medically appropriate, Gastric Stapling is the only obesity surgery eligible for benefit coverage approval." It instructed her that the Predetermination for Benefits form had to be filled out prior to surgery to allow Central States a chance to determine if the proposed surgery was "medically appropriate."

Exbom's form was reviewed by three medical consultants for Central States. All three recommended that her request for coverage be denied. Their view was that the proposed surgery was both cosmetic and experimental in nature and therefore unpayable under the terms of the Plan. Central States adopted their recommendation and denied Exbom's coverage request.

She appealed. Central States has an appeal process as mandated by section 503 of the Employee Retirement Income Security Act of 1974, 29 U.S.C. Sec. 1133. The process consists of three steps. In the first step ("Level I") Central States's Health and Welfare Communications Department reviews the claimant's request for benefits and the relevant evidence, including medical opinions. As the subject matter of the appeal is inevitably medical in nature, the decisionmakers maintain medical consultants and often rely heavily on opinions provided by them. This is so not only in Level I, but throughout the appeal process. In the second step ("Level II") a Claim Appeal Committee reviews the Level I decision, the request, and the relevant evidence. In the third step ("Level III") Central States's Board of Trustees reviews the request, all of the evidence, and all of the prior decisions, and then makes a final, binding decision. At each stage in the appeal process the claimant may submit additional information that she wants the decisionmakers to consider. The claimant may also review the appeal file, so her submitted information may address the concerns communicated by the decisionmakers.

Exbom's appeal was denied at both Level I and Level II. She took it to Level III, where in November of 1987 the Board of Trustees considered her request for coverage. In so doing the Trustees reviewed a mass of information, including statements from several of Exbom's doctors. The gist of these statements was that Exbom was morbidly obese, that her morbid obesity had led to physical and psychological problems, that she was likely to remain obese without a gastroplasty, and that a gastroplasty was an "accepted mode of treatment in the United States." Also among the information were the recommendations of Central States's medical consultants. One of these consultants, Dr. Buckingham, had reviewed Exbom's case three times (each time as new information was submitted). Dr. Buckingham was of the opinion that the medical benefits of gastroplasties were unknown. The literature on the procedure had failed to establish that it could cure obesity-related problems, including the problems Exbom purportedly was suffering from. Moreover, Dr. Buckingham felt that the medical risks of gastroplasties were unknown. He noted that weight-loss surgery often resulted in later complications, and pointed out that Exbom's weight-loss operation in 1979 had to be revised in 1986 for this very reason. Due to these uncertainties and on the basis of all the evidence, Dr. Buckingham believed that Exbom's proposed surgery was experimental in nature.

He also felt that it was cosmetic. He noted that Exbom was then 48 years old and suffering from a variety of obesity-related health problems. He opined that "the proposed surgery does not cure diseases related to obesity" and, therefore, the surgery was not medically necessary. The doctor admitted that in the past he had recommended payment for other gastric stapling procedures, but said that he had recommended those surgeries only for obese patients who were young and who suffered no obesity-related medical problems. He recommended the surgery in the hope that it would prevent those problems from occurring at a later date. It was his opinion, however, that the surgery was not medically helpful (although it could be aesthetically pleasing) once problems had developed. And in this case problems had developed.

In light of Dr. Buckingham's opinion, and after considering all other documents, evidence, and prior opinions and interpreting the terms of the C-6 Plan, the Trustees denied Exbom's Level III appeal. They found that the surgery she proposed was cosmetic and experimental in nature. By letter dated November 25, 1987, she was informed of their decision.

In June of 1988 Exbom filed suit in federal court against Central States. She brought an action that sought to have the Trustees' denial of her benefits overturned pursuant to ERISA Sec. 502(a)(1)(B), 29 U.S.C. Sec. 1132(a)(1)(B). ^* Section 1132(a)(1)(B) gives a member of a plan standing to sue "to recover benefits due to him under the terms of the plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." Exbom's suit progressed until it came before the district court on cross-motions for summary judgment. In an opinion entered March 21, 1989, the district court disposed of the action by granting Central States's motion. The court found no reason to upset the Trustees' decision; in its view they did not act arbitrarily or capriciously in denying...