Comments, clarifications, questions or just total confusion? So has final say?????????????
does anyone here have expert experience dealing with uhc group insurance and california laws that apply to contracts written here but implemented in other states?
will try to be as brief as possible. I have United health Care Choice Plus and the policy is written in and governed by law in California. Any treatment for obesity is listed as an exclusion ( including medical necessity)and I live in Maryland. I an trying to find out if there is a way they are required to cover the surgery.
I have contacted my benefits rep and asked for a rider. She told me that it could not be done on an individual basis it would have to be done for the entire company. She is checking on it for me. I just want to know excactly what my chances are of really being able to get this paid for.
With out it I am sentenced to a life of pain, limited mobility and many additional co morbidities
possible early death and I do not want die young like my mother did. ( her age at death 57 and my current age is 51) I am need of a total knee replacement and my ortho does not want to do it becuase of my weight. He feels if the weight comes down i may be able to delay the tkr for maybe 10 yrs. If it is done now there is a good chance of having a lot of revisions or even possible amputation if the shin bones shatters or my thigh bone becomes dislocated.
actually work for UHC in the Appeals Department and I
can tell you that the benefits differ from state to state and
California laws are very different from all other states. Have
you been denied surgery and have you appealed the denial?
Thanks for the response. No I have not been denied as of yet.
I live/work in the state of Maryland. UHC is my group health insurance and the policy is written in and governed by the state of California. My employer has any treatment for obesity as an exclusion. The health insurnace is not self funded by my company and they have employees all over the world. My paper work has not even been submitted yet for the surgery and won't be until i fininsh all of the preliminaries. which will happen by June 1.
I know that they require a 5 yr history of obesity, BMI of at least 40 or 35 with co morbidities of which i do have . ( hi blood pressure, anxiety, hi cholestoral, and sever osteoarthritis in my knees to the point that I saw an ortho about a total knee replacement. He does not want to it at this point due to my weight. I currently can walk or stand for very long ( like 15 minutes max) driving. housework, intimacy and social events are difficult because either I can't keep up or I am in so much pain that I have to set on the side lines.
Below is a section of the law for the state of Maryland and I have been looking for a definition or interpretation of the phrase below in bold type. (lines 24, 25, 26, and 27. Any comments advice that would be of helpful is greatly appreciated.
Lori
Article - Insurance
will try to be as brief as possible. I have United health Care Choice Plus and the policy is written in and governed by law in California. Any treatment for obesity is listed as an exclusion ( including medical necessity)and I live in Maryland. I an trying to find out if there is a way they are required to cover the surgery.
I have contacted my benefits rep and asked for a rider. She told me that it could not be done on an individual basis it would have to be done for the entire company. She is checking on it for me. I just want to know excactly what my chances are of really being able to get this paid for.
With out it I am sentenced to a life of pain, limited mobility and many additional co morbidities
possible early death and I do not want die young like my mother did. ( her age at death 57 and my current age is 51) I am need of a total knee replacement and my ortho does not want to do it becuase of my weight. He feels if the weight comes down i may be able to delay the tkr for maybe 10 yrs. If it is done now there is a good chance of having a lot of revisions or even possible amputation if the shin bones shatters or my thigh bone becomes dislocated.
actually work for UHC in the Appeals Department and I
can tell you that the benefits differ from state to state and
California laws are very different from all other states. Have
you been denied surgery and have you appealed the denial?
Thanks for the response. No I have not been denied as of yet.
I live/work in the state of Maryland. UHC is my group health insurance and the policy is written in and governed by the state of California. My employer has any treatment for obesity as an exclusion. The health insurnace is not self funded by my company and they have employees all over the world. My paper work has not even been submitted yet for the surgery and won't be until i fininsh all of the preliminaries. which will happen by June 1.
I know that they require a 5 yr history of obesity, BMI of at least 40 or 35 with co morbidities of which i do have . ( hi blood pressure, anxiety, hi cholestoral, and sever osteoarthritis in my knees to the point that I saw an ortho about a total knee replacement. He does not want to it at this point due to my weight. I currently can walk or stand for very long ( like 15 minutes max) driving. housework, intimacy and social events are difficult because either I can't keep up or I am in so much pain that I have to set on the side lines.
Below is a section of the law for the state of Maryland and I have been looking for a definition or interpretation of the phrase below in bold type. (lines 24, 25, 26, and 27. Any comments advice that would be of helpful is greatly appreciated.
Lori
Article - Insurance
15 15-835.
16 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS
17 INDICATED.
18 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO
19 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN
20 KILOGRAMS BY THE HEIGHT IN METERS SQUARED.
21 (3) "MORBID OBESITY" MEANS A BODY MASS INDEX GREATER THAN 40
22 KILOGRAMS PER METER SQUARED.
23 (B) THIS SECTION APPLIES TO:
24 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE
25 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN
26 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS
27 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND
28 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL,
29 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS
30 THAT ARE ISSUED OR DELIVERED IN THE STATE.
31 (C) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE COVERAGE FOR
32 THE EXPENSES INCURRED BY A PATIENT WITH MORBID OBESITY FOR ESTABLISHED
33 SURGICAL TREATMENT IF:
34 (1) A PHYSICIAN DETERMINES THAT SURGICAL TREATMENT
never settle for less than you deserve and you deserve only the best. 
definitely appeal if you get denied. My friend in PA was all set to go and 2 weeks before surgery, was told that her insurance had an exclusion regarding bariatric surgery. She was devastated.
You might want to call the Maryland Insurance Commission to find out what your employer is obligated to supply. If they are self-funded, they don't have to follow any of the MD rules (you said they weren't self-funded). But I am not sure what happens if the jurisdiction for your insurance is California and you live in MD. I work for an insurance company and I know that I've had a few patients that lived in one state (i.e. Maryland) but their jurisdiction for their insurance was another state (i.e. Virginia)...in that case the jurisdiction ruled, not the location of the patient. This situation was related to speech therapy and in MD & DC they have a "habilitative" benefit that covers therapy up to age 19, but in Virginia, it's "early intervention" and only covered to age 3. The benefit to age 19 was definitely the better option, but because of the jurisdiction, they didn't get it.
I do know, however, from working for an insurance company, a lot of stuff gets overturned in appeals, so definitely appeal.
You might want to call the Maryland Insurance Commission to find out what your employer is obligated to supply. If they are self-funded, they don't have to follow any of the MD rules (you said they weren't self-funded). But I am not sure what happens if the jurisdiction for your insurance is California and you live in MD. I work for an insurance company and I know that I've had a few patients that lived in one state (i.e. Maryland) but their jurisdiction for their insurance was another state (i.e. Virginia)...in that case the jurisdiction ruled, not the location of the patient. This situation was related to speech therapy and in MD & DC they have a "habilitative" benefit that covers therapy up to age 19, but in Virginia, it's "early intervention" and only covered to age 3. The benefit to age 19 was definitely the better option, but because of the jurisdiction, they didn't get it.
I do know, however, from working for an insurance company, a lot of stuff gets overturned in appeals, so definitely appeal.
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