dead end?

I have posted before that I live in FL bit have BCBS Horzion of NJ through my husband's job. I reccently got the ball rolling with a local surgeon. Was getting everything in place, when my husband asked the Hr depot at his job about possible exculsion they have have on the operation. Sure enough they have one. It has been in place right at a year. They advised him it was a dead end. is this true? Am I stuck?

Kala, I would not take this initial No as the final answer. I would call HR myself and ask them to read you the part of the policy that excludes WLS. Often it says something like the policy excludes WLS unless it is deemed medically necessary or something like that. Don't you love it... Sometimes the exclusion includes an exception. You might also call the insurer directly and inquire on what the policy says and if their are any exceptions. Hang in there and don't give up! Kat

There is a gentleman that posts on the DS board from NJ and he posted a message not too long ago about there being some laws in NJ about insurance having to cover WLS. I do not know all the particulars and I imagine there might be some differences if the insurance plan was self funded or not, but I would get in touch with the insurance company in NJ to find out about the coverage, sometimes the HR departments do not know everything. I would also post a question on the NJ message board. If the insurance is though BCBS in NJ then the NJ laws govern the coverage not Florida law. Your surgeon's office should be able to get a straight answer from the insurance company. I will send a link to your message to Walter and see if he will advise you about what he found out about the NJ law. Red

Kala, My husband is covered by Horizon BCBS of NJ. Our policy states that wls must be medically necessary. I was approved & had my gastric bypass almost 1 year ago (1/25/05). The only problem I had getting approval was they said they didn't receive the info the surgeon sent the first 2 times and had to re-submit it 3 times before it was reviewed and approved. Be prepared to document previous weight loss attempts under a doctor's supervision (my PCP printed out his visit notes for every time we discussed my weight and what I was doing to try to lose weight for 5 years!), and a psych. eval. They don't move quickly, but if you have several co-morbidities and stay on them you may get approved. I agree with the other posts, don't take some one's word that it is a dead end. If you don't have a copy of your insurance contract, call your HR dept. and ask them to e-mail or fax you a copy of the portion of contract that pertains to wls and read it for yourself. Even if it is a full exclusion (doesn't specify "medical neccessity") I would still apply for approval, go thru their appeals process if denied and give it your best shot. You'll only be out some of your time and you never know, you might get lucky & get approved anyway. Good luck & don't give up! Vickie J. 277/146/142

NJ requires hmos to include wls as a treatment, but a HMO would not by nature extend to residence as far away as florida,from NJ. they are regional at best. you can check it out at the NJ insurance commissioners web site,