Question about insurance not following there own rules.

My insurance plan has an exclusion in it for bariatric surgery.  I suffer from numerous issues directly related to my weight. My family Dr and my Sleep Dr have both said I needed surgery and to try an appeal.  

I appleaed the exclusion with my insurance company (anthem) and sent all the appropriate paperwork in certified mail.  They received the letter on August 22nd. They did not respond to the appeal until November 8th. 

According to my policy they have to answer appeals within 30 days.  I contacted them numerous time after the 30 days had passed and was told each time that they were "working on it" and they would contact me back via email or phone and let me know how it was going.  Each time they never responded back.  

The last time I called I finally got really nasty with them and demanded an answer.  The lady I was speaking with said she would send it to a manager and that I would get a response the next day.  That also didn't happen.  After about a week I got the denial letter.  

The company I work for uses a company to negotiate rates and get our insurance. It just happened to be open enrollment this week so I went and told them what happened. She emailed anthem saying I was going to contact an attorney and would be contacting the state insurance commission,  Both of which I do plan doing.  

Sorry to be so long winded about this but does anyone know if I can get them to cover it since they broke their own policy with the appeals process? 

The exclusion is on your employer NOT Anthem!!!   If you want the surgery, you have to persuade your employer to pay for it or to not exclude it in this cycle!

No, even though they did not adhere to the specified time frame for processing the appeal, your policy specifically excludes WLS and you have not paid the premiums for a more expensive plan that covers it.  You cannot force them to cover a procedure that is excluded.  Period.

Contacting an attorney will cost you money and gain you nothing, I'm afraid.

Lora

Yeah.

My renters insurance specifically does not cover flooding.  If I wanted flood insurance, I'd have to pay more money for it.  So if my apartment floods, there is no way my insurance is going to cover the damage.

Same with your insurance policy.  It specifically doesn't cover WLS.  If you want WLS coverage, you'll have to pay for insurance that covers it.

Sorry, but if your policy excludes wls all the appeals & lawyers won't help you, look into getting a policy on your own that includes wls or pay for it on your own, there's really no getting around it. It sucks to pay for insurance that won't cover what you want, but that's just how it is.

My story was a bit similar to yours.  The first time I tried for WLS I got the check list and number one on the sheet was the insurance company and verify coverage.  I made the call noted the date, time and the person I talked to, and according to them I was good to go.  I jumped thru all of the hoops and was one week from surgery and was denied.  I also had letters from doctors stating that it would greatly benefit my health

It ends up that the rep did not go into my company's specific plan to check.  I appealed all the way up to the state level and was told that it my company was self insured and can do what they want and the state can do nothing to stop it.  Even though the representative said otherwise.

5 years later my plans with work changed and WLS is accepted, but I had to start the ball rolling again.  To make a long story short I am 2 months out of surgery and I am 55 pounds down. 

I know how hard it was getting told no.  I got depressed over it, but I did not give up on doing it.  Before my company changed the coverage I was looking to pay out of pocket.

Good luck and keep the faith.

Chris

Sorry you have no case.  Try to convince your employer to pick it up or buy your own with Obama care