                             In the
 United States Court of Appeals
               For the Seventh Circuit
                          ____________

No. 04-1797
TERRY L. MANNY,
                                                 Plaintiff-Appellant,
                                 v.


CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS
PENSION AND HEALTH AND WELFARE FUNDS,
                                                Defendant-Appellee.

                          ____________
         Appeal from the United States District Court for the
           Northern District of Illinois, Eastern Division.
           No. 02 C 9535—Charles R. Norgle, Sr., Judge.
                          ____________
    ARGUED OCTOBER 1, 2004—DECIDED OCTOBER 26, 2004
                          ____________



  Before FLAUM, Chief Judge, and BAUER and POSNER, Circuit
Judges.
  POSNER, Circuit Judge. Terry Manny, a 58-year-old truck
driver who is a participant in an ERISA welfare plan, asked
the trustees who administer the plan to cover the expense of
a proposed gastric-bypass operation. Manny, who is 6 foot
1 inch tall and weighs 470 pounds, suffers from a variety of
serious health conditions undoubtedly caused or exacer-
bated by his obesity, including type 2 diabetes (his pancreas
2                                                  No. 04-1797

produces insulin, but not enough to eliminate excess sugar
from his blood), high blood pressure, joint and respiratory
problems, swelling of his legs and feet, lower back pain, and
depression. The trustees ruled that the plan does not cover
such an operation, precipitating this suit, which the district
court dismissed on the ground that the trustees’ decision
was not an unreasonable interpretation of the plan.
  Because the plan confers on the trustees “discretionary
and final authority in making . . . decisions interpreting plan
documents,” judicial review of their interpretations is
deferential. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,
115 (1989). And conflict of interest is not a concern with re-
spect to the present plan, as it sometimes is when an
insurance company is both plan administrator and insurer
of benefits, or when the employer is the administrator of a
self-funded single-employer plan. Pinto v. Reliance Standard
Life Ins. Co., 214 F.3d 377 (3d Cir. 2000); Kathryn J. Kennedy,
“Judicial Standard of Review in ERISA Benefit Claim Cases,”
50 Am. U.L. Rev. 1083, 1146-53 (2001). The deferential
standard that courts use in reviewing determinations made
by trustees to whom the plan gives discretion to interpret—
the “arbitrary and capricious” standard, Firestone Tire &
Rubber Co. v. Bruch, supra, 489 U.S. at 115; Dabertin v. HCR
Manor Care, Inc., 373 F.3d 822, 827-28 (7th Cir. 2004); Daill v.
Sheet Metal Workers’ Local 73 Pension Fund, 100 F.3d 62, 67-68
(7th Cir. 1996)—is “a range, not a point.” Van Boxel v. Journal
Co. Employee’s Pension Trust, 836 F.2d 1048, 1052-53 (7th Cir.
1988). It is “a sliding scale” that requires that judicial review
be “more penetrating the greater is the suspicion of partial-
ity, less penetrating the smaller that suspicion is.” Id. A
conflict of interest on the part of the plan’s trustees may
start a slide. Chojnaki v. Georgia-Pacific Corp., 108 F.3d 810,
815 (7th Cir. 1997).
  But not in this case. The teamsters plan is a multi-em-
ployer welfare plan the trustees of which are required to
No. 04-1797                                                  3

consist of an equal number of union and employer represen-
tatives. 29 U.S.C. § 186(c)(5)(B); Connolly v. Pension Benefits
Guaranty Corp., 475 U.S. 211, 232 (1986). The union trustees,
at least, have no discernible incentive to rule against an
applicant. And the trustees were unanimous in turning
down Manny’s application. Given the language of the plan
conferring interpretive authority on the trustees and the
absence of a conflict of interest, the only question for us is
whether the trustees’ interpretation of the plan was com-
pletely unreasonable.
  The plan defines “cosmetic” as “care, treatment, services
or supplies the primary effect of which is to improve the
physical appearance. . . . The fact that there may be an inci-
dental medical benefit does not prevent a determination that
the care, treatment, services or supplies are cosmetic.” With
regard to such care, etc., the plan goes on to provide as
follows:
    4.08 EXCLUSION FOR PAYMENT FOR TREATMENT
    CONNECTED WITH SURGERY FOR COSMETIC
    PURPOSES
    A Covered Individual shall not be entitled to payment
    on a claim for benefits for any charge incurred for treat-
    ment or service connected with a cosmetic procedure,
    even if performed for psychological reasons, unless the
    treatment or service is medically required as a result of
    an Accidental Bodily Injury incurred while a Covered
    Individual.
    This exclusion includes, but is not limited to:
    (a) Any surgery primarily for obesity, including gastric
    bypass, gastric stapling, intestinal bypass, lipectomy,
    suction lipectomy, panniculectomy, and any other surgi-
    cal procedure, a purpose and result of which is primar-
    ily to remove adipose tissue;
4                                                 No. 04-1797

    (b) Augmentation mammoplasty, unless part of recon-
    structive surgery for the treatment of malignancy of the
    breast necessitating removal of a portion or all of the
    breast tissue;
    (c) Rhinoplasty, unless the patient has sustained a
    traumatic fracture of the nasal septum, or unless the
    patient has chronic nasal obstruction and the procedure
    is undertaken to relieve this obstruction;
    (d) Otoplasty for irregular deformity or macrotia. This
    is sometimes referred to as plastic surgery for lop ears
    or cauliflower ears;
    (e) Blepharoplasty, or repair of drooping eyelids, unless
    the droop of the eyelids is such as to restrict the field of
    vision and the visual field restriction is documented by
    the ophthalmological consultant;
    (f) Radical Keratectomy or Keratotomy, unless the pa-
    tient has myopia of such a severe degree that it cannot
    be corrected by lenses;
    (g) Rhytidectomy (face lift);
    (h) Dyschromia (tattoo removal); and
    (i) Genioplasty (chin augmentation).
  How all this bears on Manny’s claim is unclear. Section
4.08 begins by excluding benefits for “treatment or service
connected with a cosmetic procedure,” and if that were all
the plan said, Manny might be home free. While some peo-
ple may undergo the dangerous and painful procedure of a
gastric-bypass or gastric-stapling operation merely to look
better, Manny is not one of them. He wants the operation for
health reasons. The “medical benefit” that he seeks is not
“incidental.” And the “primary effect” of the operation
would not be “to improve [his] physical appearance”; that
would be an incidental effect. Of course, should the op-
No. 04-1797                                                 5

eration cause Manny to lose weight yet not yield any medi-
cal benefit, then its primary and indeed only effect would be
to improve his appearance. But probably “primary effect”
means primary intended effect; this is implied, as we’ll see,
by the exceptions to the exclusion discussed next.
   The second paragraph of section 4.08 explains that the
exclusion of cosmetic procedures from coverage extends to
“any surgery primarily for obesity, including gastric by-
pass, . . . and any other surgical procedure, a purpose and
result of which is primarily to remove adipose [i.e., fatty]
tissue.” A gastric-bypass operation is “surgery primarily for
obesity.” In fact, the word “primarily” could be deleted
without loss of meaning. The sole purpose and only effect
of the operation are to shrink the patient’s fatty tissue by
reducing the ability of his gastrointestinal system to convert
food to fatty tissue. The shrinkage is valued not in itself,
however, but only as a means to a further end. As is true of
all surgery. The purpose of an operation to remove a tattoo
is to remove the tattoo, but the usual reason for wanting to
remove it—the end to which removal is the means— is not
love of surgery but that the tattoo is unsightly or embarrass-
ing.
  So while the first paragraph of section 4.08 leans in favor
of coverage of gastric-bypass operations motivated solely by
concern with health, the second paragraph appears to
contain a categorical exclusion of such operations. When
different clauses of a contract clash, creating an ambiguity,
we have an interpretive task confided in this instance to the
teamster plan’s trustees. We cannot say that their interpreta-
tion is unreasonable, especially in light of the treatment in
the second paragraph of section 4.08 of other procedures
that are excluded from coverage as being “cosmetic.” Im-
portantly, some of these exclusions are qualified and others
not. Breast augmentation is excluded “unless” it is moti-
6                                                No. 04-1797

vated by loss of breast tissue as a result of breast cancer.
Operations to reshape the eyeball are excluded “unless”
they are necessary to correct myopia that is so severe that it
can’t be corrected by glasses. (There are similar “unless”
exceptions for “nose jobs” and repairs of drooping eyelids.)
Most breast-augmentation operations and most operations
to reshape the eyeballs are driven by the desire to improve
one’s normal appearance. But some are necessary to avoid
disfigurement or to enable a person to see, and these are
excepted from the exclusion even if, to return to an earlier
point, the operation fails to achieve its medical purpose and
thus yields merely a cosmetic benefit. Several other pro-
cedures listed in the exclusion, however, are excluded alto-
gether, without exception. Tattoo removal is not covered even
if the removal is necessary to prevent infection. Similarly,
surgery to reduce obesity is excluded whether driven by
vanity or health concerns.
   Granted, there is a difference between breast augmenta-
tion and eyeball-reshaping, on the one hand, and gastric
bypass or gastric stapling on the other hand. Most of the
operations of the former two types (and likewise most “nose
jobs” and eyelid operations) are motivated by cosmetic
considerations as defined in the plan. Indeed, all are so
motivated in the case of breast augmentation. (Even when
the augmentation is designed to reconstruct a breast
amputated in a mastectomy, the objective is to alter the pa-
tient’s physical appearance rather than to ward off a further
illness—but it is to restore rather than to improve normal
appearance and this limits potential abuses of coverage.) In
contrast, most obesity surgery is motivated exclusively by
health concerns. These operations are dangerous and are
rarely performed other than on people like Manny who are
morbidly obese, American Gastroenterological Association,
“Medical Position Statement on Obesity,” 123 Gastroenterology
879, 881 (2002), “morbid” here denoting a degree of obesity
that is highly dangerous to the individual’s health.
No. 04-1797                                                  7

  Probably the operations are nonetheless excluded from
the plan’s coverage not only because they are expensive
(and welfare funds have limited assets) but also because, while
they have their strong defenders, see, e.g., Henry Buchenwald
et al., “Bariatric Surgery: A Systematic Review and Meta-
Analysis,” 292 JAMA 1724 (2004); Robert E. Brolin, “Bariatric
Surgery and Long-Term Control of Morbid Obesity,” 288
JAMA 2793 (2002); Alan C. Wittgrove & G. Wesley Clark,
“Laparoscopic Gastric Bypass, Roux en-Y—500 Patients:
Technique and Results, with 3-60 Month Follow-up,” 10
Obesity Surg. 233 (2000), they are controversial. Many medical
experts are of two minds on whether surgery to reduce
obesity produces health benefits commensurate with the
danger of such surgery. Mike Mitka, “Surgery for Obesity:
Demand Soars Amid Scientific, Ethical Questions,” 289 JAMA
1761, 1762 (2003); C. David Sjöström et al., “Differentiated
Long-Term Effects of Intentional Weight Loss on Diabetes
and Hypertension,” 36 Hypertension 20 (2000); Gina Kolata,
“Health and Money Issues Arise Over Who Pays for Weight
Loss,” N.Y. Times (late ed.), Sept. 30, 2004, p. A1. A recent
study found that the surgery kills 2 percent of extremely
obese patients, such as Manny, on whom it is performed.
David R. Flum & E. Patchen Dellinger, “Impact of Gastric
Bypass Operation on Survival: A Population-Based Analysis,”
199 J. Am. College of Surgeons 543, 547 (2004).
  Obviously we’re not going to try to referee the debate. The
point is only that it would be no surprise if section 4.08 had
indeed been intended to exclude all obesity surgery from
coverage, as the trustees found. But there is one thing to
give us pause, and that is their submission of Manny’s
medical records to the plan’s medical consultant, Dr. William
B. Buckingham. In Exbom v. Central States, Southeast &
Southwest Areas Health & Welfare Fund, 900 F.2d 1138 (7th
Cir. 1990), a case that involved another morbidly obese team-
ster wanting obesity surgery, and the same plan, Buckingham
8                                                No. 04-1797

assumed that gastric-stapling operations were covered by
the plan if medically necessary; he just believed that Exbom
did not have a medical need for the operation. Id. at 1140.
There are a number of similar cases. See Roberts v. Central
States, Southeast & Southwest Areas Health & Welfare Fund
Plan 503, No. 97-1454-CV-W-5 (W.D. Mo. Sept. 15, 1998);
Livingston v. Central States, Southeast & Southwest Areas
Health & Welfare Fund, 900 F. Supp. 108 (E.D. Mich. 1995);
Strader v. Central States, Southeast & Southwest Areas Health
& Welfare Fund, No. 86-3340-CV-S-4 (W.D. Mo. May 4, 1987);
Berry v. Central States Southeast & Southwest Areas Health &
Welfare Fund, No. Civ-1-86-004 (E.D. Tenn. Jul. 22, 1986). Yet
in the present case Buckingham changed his tune and
testified that gastric-bypass operations, and presumably
gastric-stapling operations as well (for that was the opera-
tion sought by Exbom, and it is treated the same in the plan),
are always within the plan’s exclusion for surgery to correct
obesity. Buckingham “states that gastric bypass . . . is spe-
cifically excluded from coverage in the Plan document. He
explains that our experience is that this procedure does not
constitute treatment of co mobilities [sic—’comorbidities’]
such as sleep apnea, diabetes, hypertension and cardiac dis-
ease. In addition, the initial weight loss usually is regained
after this procedure. He feels that it is NOT physically pos-
sible to gain or maintain weight without excessive eating
and this procedure is not medically necessary.”
  There has been, however, a change in the plan language
between Exbom (and the other cases we cited) and the pres-
ent case. Under the earlier language a procedure was “cos-
metic” only if it did not “correct or materially relieve a
medical condition.” This definition has been broadened; as
we know, the plan now defines “cosmetic” as “care, treat-
ment, services or supplies the primary effect of which is to
improve physical appearance. . . . The fact that there may be
an incidental medical benefit does not prevent a determi-
No. 04-1797                                                   9

nation that the care, treatment, services or supplies are
cosmetic.” The tension between the definition of “cosmetic”
and the specific exclusion of obesity surgery was greater
under the old language, and this may explain the different
interpretations by Buckingham, endorsed by the trustees.
Moreover, Exbom was decided a decade and a half ago, and
what may have seemed a promising procedure then may
not seem so now in the light of the longer experience with
it.
   Admittedly it is odd for a doctor to be testifying about the
meaning of a medical plan. With rare exceptions the
interpretation of a document is a task that a judge or other
resolver of legal disputes performs without the aid of tes-
timony, expert or otherwise. In some state courts, however,
legislators testify to the legislative history of a statute they
voted for, Friends of Mammoth v. Board of Supervisors, 502
P.2d 1049, 1055-56 (Cal. 1972); Stewart v. Board of Medical
Quality Assurance, 143 Cal. Rptr. 641, 646-47 (App. 1978), and
perhaps Buckingham’s testimony should be viewed in that
light. See also Indiana Aeronautics Comm’n v. Ambassadair,
Inc., 368 N.E.2d 1340, 1344 (Ind. 1977). Trustees are not
bound by the rules of evidence. We pointed out, moreover,
that one thing that would make it plausible to think that the
draftsmen of the teamsters plan had excluded surgery for
obesity without exception would be skepticism in the
medical profession about the medical value of such surgery,
a skepticism that might have moved Buckingham to suggest
the exclusion to the drafters of the plan. Or perhaps the
purpose of Buckingham’s testimony was to provide a
fallback position for the plan: that even if a gastric-bypass
operation is sometimes covered by the plan, it shouldn’t be
in the present case.
  Manny’s case is an appealing one, but there is no doubt
that the trustees were acting reasonably in interpreting the
10                                                No. 04-1797

plan to exclude coverage for gastric-bypass operations.
(There is also no doubt that the trustees based their decision
on an interpretation of the plan as excluding coverage for all
such operations, rather than on a judgment that Manny’s
motivation was cosmetic rather than health.) Indeed, for all
we know, they were acting in Manny’s own best interests.
The surgery that he wants is dangerous, and of uncertain
value. His medical problems, though undoubtedly aggra-
vated by 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’ interpre-
tation of the plan; it was reasonable, so our hands are tied.
                                                   AFFIRMED.
A true Copy:
        Teste:

                           _____________________________
                            Clerk of the United States Court of
                              Appeals for the Seventh Circuit




                    USCA-02-C-0072—10-26-04
