Overturning an exclusion? Is it possible?
Ok, so here is the deal.
Effective January 1st 2015, I will be insured through UMR. My understanding is UMR is a 3rd Party Claims Administrator, and my employer is 'self insured.' Meaning it is my employer that pays the cost but they administer the claims. I checked with my HR dept if Bariatric Surgery was covered and they advised it was excluded. I have been asking them for my full policy, binder, fine print, etc because I want to see if its excluded are there any loopholes or exceptions to the exclusions, i.e. comorbidities, bmi, etc. they just cant seem to get it to me.
My question is since they are telling me its excluded. Is this a lost battle? Can an exclusion be overturned based on doctor referrals, or really high BMI. My current bmi is 49 (craaaazy high). People always tell me insurance providers will ALWAYS deny or say its not covered but w the right buttons pressed, they will give in.
When I went through my appeal with Walter Lindstom's office, they explained that in certain cir****tances, patients can have their cases reviewed by a third party and qualify despite exclusions present in the plans. It'll take some work but it apparently can be done. If you reach out to them, they will give you a free consult in which they will answer all of your questions. I cannot recommend them highly enough.
good luck!
Sleeved 6/12/13 - 100 pounds lost to get to goal!
It can't be overturned with a doctor's referral, no. What it means is that you have paid for an insurance policy that does not cover WLS. Since you haven't paid for WLS coverage, they are not going to cover it.
My renter's insurance doesn't cover flooding. If I wanted flood insurance, I'd have to pay more for it. Since I haven't paid for flood insurance, my insurance isn't going to pay for the damage if my apartment is flooded, even if it's flooded really bad, even if I get a referral from someone.
What you can do is ask your employer to to offer insurance that does cover WLS.
Your insurance provider should not say something is not covered if it is, nor should they deny it if it is covered. They must tell you what is and is not covered and they must pay for covered services if you meet whatever guidelines are in place in your policy. It would be illegal for them to take your money for insurance but then refuse to cover stuff your policy covers.
Kelly
Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.
What Kelly said. I have heard reports on here of how attorneys might be able to help, but I have never read of anyone on here (or anyone I know outside of Obesity Help) actually getting an exclusion overturned. Because of the cost of the surgery itself and the cost of follow up and for complications the first two years is so high, policies that include bariatric surgery usually have significantly higher premiums and your employer has chosen not to pay the increased cost in order to keep costs down.
Sorry, but the insurance company is not going to just "give in" and cover something that is excluded just because you push them and try to convince them taht you need it. Despite what some cynical people may say, the only time an insurance company will "always" deny WLS is when it is excluded. If the procedure is covered by the plan and the employee shows that they meet the criteria, the surgery is approved right away the vast majority of the time. Even when people get an initial denial when WLS is covered by their plan, it is usually just a matter of the insurance company not having received all of the necessary documentation.
Also, although a BMI of 49 might seem "crazy high" to you (and I completely understand that), in the world of WLS (and insurance coverage) it really isn't. MANY people start with BMIs of over 50 (the "super morbidly obese" category).
You can certainly contact an attorney, but it is almost certainly going to be a waste of money.
Lora
14 years out; 190 pounds lost, 165 pound loss maintained
You don't drown by falling in the water. You drown by staying there.
