Contradicting Exclusions

My employer is self insured. Our "Plan" exclusions states surgery primarily for weight loss or obesity is not covered. THERE IS NO MENTION OF MEDICAL NECESSITY HERE!! ***BUT*** There is another exclusion that states hospitalizations/services that are NOT medically necessary are NOT covered. ***SO*** Does that mean that MEDCALLY NECESSARY hospitalizations ARE covered??? I'm splitting hairs here, I know.... But my HR rep told me that I'll be denied right off the bat, and chances of appeal are slim to none (with slim on his way out to lunch..) I'm preparign myself for legal action and I haven't even had my surgeon consult yet!! Anywho- How good are these surgeons at creative writting for insuance approvals? HR rep said if the inital letter is to request surgery for obesity it will be denied, but if its reqesting surgery for treatment of comorbidities it stands a better chance. Any help here will be greatly appreciated!! I'm so stressed out over this I have trouble sleeping... Ever since I made up my mind about getting the surgery (Looking at Lab-band now.) I haven't been able to think of anything else!! Am I wierd or something???

There is another exclusion that states hospitalizations/services that are NOT medically necessary are NOT covered. ***SO*** Does that mean that MEDCALLY NECESSARY hospitalizations ARE covered??? Yes, but this exclusion is usually in response to plastic surgery or hospitalization that is elective. When obesity surgery is excluded, then even the hospital is excluded because it is considered elective and not approved. My employer is self insured. Our "Plan" exclusions states surgery primarily for weight loss or obesity is not covered. THERE IS NO MENTION OF MEDICAL NECESSITY HERE!! This is because even if the WLS is considered "medically necessary" it will not be covered. HR rep said if the inital letter is to request surgery for obesity it will be denied, but if its reqesting surgery for treatment of comorbidities it stands a better chance. Now I am not sure what she meant by this... WLS is just that. I don't know what your co-morbs are but if you had diabetes, did she mean you submit the paperwork as a diabetes surgery? Honestly, while I wish that could work, I don't think it would in that case. Unfortunately, exclusions are horrid and unless your employer will purchase a rider or change their policy, you are not likely to beat it. Maybe you should get a face-to-face appointment with the HR person in charge of these benefits so that you can discuss it in depth. Go to the appointment armed with the numbers (how WLS is cheaper in the long run) etc. And you are not alone... Since I have made this decision, I cannot wait for the journey to begin. It is like waiting for the train to take you to your new and better life and the conductor keeps telling you that the train is delayed!!!

PFFFT..... My train is heading for one fo those painted-on black tunnel openings, like in the cartoons!!! SPLATTT!!  I can just picture the RoadRunner giggling then running away. I can't believe I've been considering changing jobs just to get health ins to cover WLS. But I'm pretty sure that'll be my only option. HR rep said I'm a smart girl and I should know that I wont be able to get the plan changed.... THE NERVE!!!!   Our corporate offices are in another state, so I wont be able to get a sit down with the people to make the changes to our crappy plan. Does anyone know if postal workers get coverage for WLS? How about wal mart? Anything in West/Central WI thats hiring?!?!? If I can make $16/hr or + and get coverage, I'll be there!!!!

Steph- what the nerve of that woman- I hope that she gets a clue or that her boss does. Being insensitive to employees that need your help? Ugh!