Update on Insurance Games

Ms N.
on 6/1/04 11:21 am - Euclid, OH

My director of benefits sent this to my insurance company because they said it was an employees appeal. I believe I have enough information from the e-mail history, and copies of some medical notes that Robbin previously gave us, to render a decision in regard to the issues in question. I'll confirm this formally when I receive the Appeal. In regard to the pre-existing condition question: 1- The last doctor's visit on record was on 4/19/03 with Dr. Webb. 2- Ms. Jones has stated that she had received no medical services from July 1, 2003 to December 31, 2003. Lacking any evidence to the contrary, I will take Robbin at her word in that regard. 3- Because Robbin had received no medical care, advise, diagnosis or treatment during the six-month period prior to her enrollment in the Plan, the Pre-Existing Exclusion clause should not be applicable. In regard to the pre-approval request for gastric bypass, absent the pre-existing condition exclusion and the fact that Ms. Jones exceeds the Plan's definition of Morbid Obesity, Acordia should have no reason to disapprove that procedure assuming that the Cleveland Clinic's established protocol for proceeding with that surgical procedure has been satisfied. In regard to the CPAP request, absent the pre-existing exclusion issue, it is our understanding that gastric bypass protocol requires that any history of sleep apnea needs management prior to the surgery. Inasmuch as the Plan covers Sleep Studies for participants who are Morbidly Obese (without six-month history), and that such a Study is required for correct calibration of a CPAP, these expenses appear to be reasonable and common preludes to the surgery itself. Please insure that the physician is aware of the apnea episodes when coordinating the prior-approval of the gastric bypass. He was on point and laid the law down....