Please Help

I was denied by my insurance company because they say that the gastric bypass is not a covered procedure. However, my certificate booklet states that it is covered if medically necessary. They are telling me that as of 1/1/06 No fully funded insurance group in Georgia is covering the procedure. Before I began this journey I called the isurance company several times and each time I was told that it is covered. Also, this year we did not receive new coverage boolets at work because we were told that our benefits did not change, however when i sent in my pre-approval that was the denial i got back. I don't understand how I can call them several times and they tell me that it is covered and then when i sumit my pre-approval they tell me it is not. My denial letter also states that since my employer has decided that it is no longer a covered benefit that I don't have any appeals left. I don't see how this is fair and I don't know what to do. Please help if you have any suggestions.

Many employers are dumping wls coverage and many more will follow this next January 1. First, call your insurance carrier or look online at their website and get a copy of their policy or clinical bulletin that explains WLS coverage. You need to make sure this is the info for your employer though. You should also be able to get this information from you HR department but if you are like me, I did not want them to know what I was looking into (privacy). My employer it is the same one as anyone can get off the Aetna website. Don't take anyone's word for it. Get the written document and understand it. If it does in fact exclude WLS as of a certain date, you may have to contact the attorney's at are on this site. Sorry, forgot their name but anyone can tell you. He is famous here. Since this is an employer health plan it is covered under ERISA as opposed to a plan you purchase on your own which is governed by state law. My suggestion is the lawyer can look at the wording to tell you if you have a chance or not. I don't think he charges much to tell you that. If the employer words the exclusion correctly your chances are about zero to get covered. I believe it is only with vague writing that you have a chance but check out the written document to be sure what it says. Also note that dieting is not the same as WLS so that is another reason you may have to have a lawyer read it for you if it says something like, "diet plans are excluded". Good Luck, Jim Randall

Jim, thank you for the reply. I have gathered the information that you suggested already and all of it says that it is covered if medically necessary. The only thing that I have that states it is not covered is my denial letter. When I log onto the insurance companies website the documentation there states that it is covered. The member certificate booklet listed is the one from last year and last year it was covered. The booklets have not been updated to say that it is not covered.

Can you type the wording for the relavent part of the denial letter? Also, ask your insurance company for the current plan for your employer regarding wls that they work off of. What is on the website may not be relevant for you as your employers plan may be different. I would not count on last years book as being correct. Your insurannce company must have something they can mail or fax to your and or point to on the web. I would think the denial letter would point to the appropriate policy and that is what you need to ask the insurance company for a copy. Jim

Jim, the denial reads as follows: This letter is to advise you that as of 1/1/06 no fully funded insured group is covering the gastric bypass surgery. We are sorry for any confusion this has caused you. Because this is ot covered by the employer there is nothing that can be appealed. I have been looking at ERISA regulations and it clearly states that you can not change a persons benefits and not tell them, which seems to be exactly what they did. This situation is so frustrating to me. I just don't know what to do.

My first thought is this is not an appropriate denial. Appeal no matter what but first ask for (1) Summary Plan Description (SPD) to understand what is in your policy and (2) Notice of Denail or more commonly, Explanation of Benefits (EOB) to get the specific reasons not a generic reponse for the reason for denial. I would fax and also follow-up with a certified letter. Remember that you only have a certain amount of time to appeal. Since this should be covered by ERISA you should be able to appeal through your State once you go through all the appeals with your insurance company. Personally I think it will be a stretch to say you were not properly notified by your employer but that is only my lay opion. They can easily say it was posted etc., but it might be worth a try. The problem I see is then you are fighting you employer and you'll have to decide if you want to do that. I definately do not want to discourage you as if were me I would give it a good try in appealing but from my understanding, if the insurance company can show you that it is no longered covered it may be hard to get an ultimate approval. If the wording is vague showing it is not covered it might help. After you get all of this information together, personnaly, I would consult with the Obesity Law Center to see if they could handle this for you. I read somewhere their help if $300 to $500 but not positive. I also think they will look at what you have and let you know if they can help you for something less than this. Jim Randall