Where can I go from here?

Hello, I am new here, at least to posting here. I am a stay at home mom to a 5 yr old and a two yr old. I am 5'3" and 290 lbs (BMI around 52). I don't have any major co-morbitities other than arthritis pain ALL the time and depression, it is also possible that I have sleep apnea. I have been reading and researching WLS for about 3 months now and I am convinced it is right for me. Sooo I started getting my ducks in a row and the first thing I do is call my insurance company (Cigna PPO). They state that there is an exclusion in the policy for WLS and that we need to talk with the employer. So my hubby talks to the head of HR and they tell him they will not change our policy but that we can call the insurance company and ask for an escalation. Anyway, he basically said we need to work something out with the insurance company. I am so confused by this and I am so depressed that this is the end of the line. There is NO WAY we can do this surgery out of pocket and DH has worked at his job for over 5 years so I don't see him getting a new job anytime soon! What if anything can I do? Has anyone ever heard of this escelation before or did the guy just give us the brush off...

ask for an exclusion, not escalation. Your hubby's probably going to have to deal with the HR people at work, and your Dr. will have to prove it is medically neccesary to have this surgery. So start the process, talk to HR and go see your PCP and get him to write a letter of neccessity and refer you to a bariatric surgeon and then pray like heck. I'm sure someone has better advice than me, I haven't dealt with Cigna, but I have read other peoples comments about it. Go to the insurers page and look around, see what others have said and done. good luck!

Call Dr.Currys office in Cincinnati. He may be able to help you. His number is -513-559-2545. Call and ask them if you are eligable for his program. They had so many spots available for free surgery. I dont know much about it but its worth calling. Good luck, Cindy

I'm not sure what they are referring to regarding an escalation and you don't want to ask for an exclusion because that is what they are telling you they have in place. It is HR's responsibility to deal with the insurance company they put in place when there is a problem. Employer's can put a rider on the policy to cover WLS. My intention is to encourage you with what I've been going through since July. I was told that my surgery was excluded from Aetna. Husbands employer told me it was excluded as well. I told everyone that I would have the surgery and they would pay because it is my only hope to save my life. I went to meet with the surgeon for a consult to make sure I could go through with this. I spoke with an attorney who told me to go as far in the process as possible before involving him. I cried in HR as I essentially pleaded for my life. I went to HR even though it's my husband's employer. I wrote a letter begging for my life but was told the insurance company refused it. Over Labor day weekend, my husband and I sat with each of my brother's families and my parents separately to tell them what we want to do and all of the risks and how my life will change and told them to say their peace now and if I die in the process, realize I was doing what I could to get help. My family started praying and I had friends that have been praying. Yesterday I got a call from HR telling me that while the insurance company excludes, the employer will consider covering it. Upon a call to the HR Benefits Coordinator I was apologized to and told to have my PCP send a compelling letter of medical necessity. Now they tell me it's only a matter of a couple of weeks to schedule. Persistance, Prayer and Patience as well as People. I must have talked to 5 people at insurance and 3 people in HR. And it isn't always the top HR people that know what is going on. I know that a strong survival instinct helped me too, because I refused to let them choose life or death for me. A squeaky wheel get's oiled. I had only just begun to squeak when the oil showed up. E-mail me anytime! Jacq

There are a couple of aspects that make the situation even more difficult. Even though we live in OH and my DH's office is in OH, the company is based out of Ontario, Canada. There is not HR personnel in this office so all communications will need to be done on the phone or thru email. My DH got lucky yesterday in that the HR director was in town for a special meeting, so DH took the director aside after the meeting. I do know that the director said that they will not change our individual insurance policy. Then he told my hubby that *we* could call the insurance and ask for an escalation. I have a feeling it was like telling us that if *we* could convince the insurance company to cover the surgery then great. Ummm... how is that gonna happen when we have an exclusion!! My hubby loves me, and while he will persue things for me as best he can I cannot see him getting really emotional to the HR dept. DH is very laid back and even asking over and over is not something he will do easily.

You are looking at being a self-pay patient. You are correct, if your husband's employer won't ok the insurance to cover a procedure that is specifically excluded from the policy, the insurance company isn't just magically going to override that contract. Unfortunately, they just don't operate that way. You can appeal or ask for escalations until you're blue in the face. You could hire attorneys-it won't do any good. The contract is the contract and you are responsible for knowing and accepting what is listed in the plan booklet at the time you sign up. Does your husband's employer offer any other plans that may offer weight loss surgery that you could switch to at enrollment time?

Yes, DH called the insurance company and that is basically what he was told. The company needs to approve coverage with a rider to the policy. My DH is sending an email asking again about the posibility of doing this but I am not holding my breath. I am really depressed, I know there is absolutely no way we can selfpay. It is not that we are low income, but this past year we put everything we had into a new house and moved... twice. All extra funds have been drained and with the new house payments we are stretched financially. Plus, a new house makes it impossible to consider a second mortgage or something along those lines... I just feel sick to my stomach, I want to be able to play with my children, have fun with my husband. I want to live again, and some idiot sitting in an office is saying my life doesn't matter.

Susan, I've dealt with insurances and won in the end. Even though your insurance has an exclusion for WLS, read your policy carefully and your benefits book too. Look for the words "medically necessary" and base your letter from your pcp on why the surgery is "medically necessary" for you to live. Find out all your comorbidities and problems that your weight causes. Do you have "incontinence" at times? Is it difficult for you to climb the steps? Have your pcp refer you for a sleep study as soon as possible. Visit "your Journey" located on the Obesity Help website. Follow the section on Insurance and insurance troubles. Keep copies of all test results and letters. If the surgery will be "medically necessary" to live a viable, independent long life then do more homework! You can send all the info with a complaint to the Ohio Insurance Commission. Almost all policies will allow procedures or surgeries if they are "medically necessary" Send in articles from the National Health Institute on their definition of morbidly obese. If you have sleep apnea, send in articles about it. If you have high cholestrol, arthritis, incontinence, depression, there are articles you can use that have scientific facts. Good Luck! Luann

Thanks for giving me a bit of hope... I am not usually a complainer so I have not talked with my PCP about a lot of my pains and problems. I got in on monday to talk to her so she will be getting quite an ear full. My PCP is a wonderful doc but I have no idea how she feels about WLS. I would also love to hear more about Dr. Curry, I read his references and he sounds great. Um.. do you mean he would just do the surgery for free? I am sure there are a LOT of people wanting that!! Does it only apply to low income? I live in Columbus so I am certainly close enough to get there. I may have to wait until monday unless they have weekend hours.