Exclusion/Insurance Issues - Attorney assistance?

Hello all. I have insurance through Aetna, which allows for the surgery given that all the proper criteria are met, but my employer has excluded this coverage as part of their policy. Is there any way around this? Would involving an attorney do anything to get my approval? I read that there are laws for certain states which deem it illegal to deny coverage of surgery on a pateient who more than needs it. Any help would be much obliged. Thanks!

Justin, I have been going thru the same issues with Carefirst Blue Choice......I can understand your frustration!!! If you are covered under a small group plan (under 50 employees) there is nothing that can be done, legally or otherwise. Yes Maryland has laws to protect people for wls, however it does not apply to small groups. If your company is more than 50 employees........you may want to continue to ask here. The only option I know is to appeal the decision. Since my coverage is for small group I am unsure of all the avenues except appeal for large groups.... Hope this helps!! Heather

I had the same problems. My husbands company was less than 50 people. I now have a different job and my insurance covers it. Good luck to you. I know it is frustrating... Bonnie r

Hi Justin I am not sure about that. But if the insurance covers it why would your employer not. You would think people would want to have a healthy employer for them. I hope it comes throught for you. Kelly

Well, I work for a large business [1500+ employees] and they HAD approved the surgery for years. In fact, I don't believe they stopped approving it until the 2006 enrollment year. The reason I mention an attorney is this-- I live more than an hour away from the closest surgeon. I don't want to log all of those miles and lose all of that time from work only to find out that the appeals process is moot-- from what I've been told, these exclusions are iron-clad. Then again, as noted above, Maryland apparently has WLS laws to protect patients. How those interact with one another is beyond, and I guess I'm just a bit confused as to how to start. Oh, and does anyone know where I can views those Maryland laws on WLS? Or give me a brief synopsis?

Hi Justin, Sorry for all your difficulties and I know it is very frustrating. You want to help yourself and give youself a better quality of life only to have the insurance company and/or employer give you problems. I know you can look under Forums at the top of the page and there is an Insurance Forum. They may be able to give you more insight or have links to MD insurance laws. Luckily, I did not have any problems with my employer or insurance company so the only advice I can give is to keep at it. Anything is possible and sometimes persistance pays off! Good luck and keep us posted! ~Heather

Justin, I'm at work right now; however, when I get home I'll email you the information. I have the legislation in a word document -- I found it while taking paralegal classes and we had to access the Maryland Code on a regular basis and one day I just came across the information and was quite surprised. Contact your benefits department to see if they know why the company excluded the surgery.

Justin, Here is the web link. This is the actual link to the Maryland Code as well as the Maryland Rules -- you'll actually be able to access any type of Maryland statute that is currently on the books. http://michie.lexisnexis.com/maryland/lpext.dll?f=templates&fn=main-h.htm&cp= Let me know if you have any problems accessing.

I must be having a mental cramp, because I'm looking through the site, and though I see a reference to gastric bypass surgery, I can't seem to find anything on the coverage. Would you mind providing me with a path there? ie: Maryland Code->Health Insurance, etc. Sorry for being difficult, but I'd love to read this and see where I stand. Oh, and I will be calling my HR department to see if they can advise me as to why they've stopped coverage. Thanks for your help! And thanks to everyone else for your help/kind words!

My wife worked for a company that had only 40 employees , but the owner paid for the coverage so my wife could get the surgery. I have ran into much trouble. I can not get regular ins cause I weight around 600 lbs and the maryland state ins plan does not cover no weight loss surgery at all. but After writng the president, and the both state senators and the governor office. they had me go and apply for medicaid at social service which has a spend down coverage and the carrier for medicaid says right in the opening it covers by-pass surgery. in this plan you must pay so much out of your pocket then medicaid will pay the rest. with surgery costing around 40-45 thousand dollars and I would have to pay about 9500 of that till they paid the rest. its based on your income. so you may want to look into this? Please don't give up.