Insurance Issue-Please Help

In January I contacted my insurance company about possibly having the gastric bypass surgery. At that time I was told that yes it was covered.  I went to the physician in February and started the process.  The doctor's office contacted my insurance company in February regarding the necessary requirements.  In March I started seeing the Nutritionist, I have now completed all the necessary steps required by the insurance company.  Yesterday I got a call from the doctor's office stating that when they called the insurance company for pre-authorization they were told that it is not a procedure covered by my policy.  I called customer service for my insurance company and was told by a very helpful representative that now I have to submit an appeal and wait for 30 days for an answer.  I have also spoken with my HR administrator whom I spoke with back in January before I contacted the insurance company , she verified that this was supposed to be a covered procedure per corporate HR.  The policy has not changed since 1/1/7.  Please help is there anything else that I can do?

It's common to be given misinformation from customer service reps at insurance companies. They stink at deciphering the verbiage in contracts. The best thing to do is find your policy plan booklet and read, for yourself, what's in black and white. If it states that you have coverage and you've got the backing from your h/r rep, then you have a case. If your policy did change at some point, however, and you in fact have an exclusion, appeals are pretty much futile. You shouldn't have to submit an appeal for their screw-up, either. They should be able to correct and reprocess with a phone call.

I am curious as to who holds the keys to your plan based on your statement that your human resources department's corporate policy is that the surgery be covered.  Do you know if you are under a self-insured plan (i.e. your company makes approval and denial decisions for treatment) or a fully funded plan (i.e. approval and denial decisions are made by the health insurance company)? If you are under a self-insured plan and you received affirmation from your company's corporate office regarding the coverage of the procedure, then you will need to go back to your human resources department to let it know the misinformation you are receiving from the insurance company so that you can work with your company to quickly resolve this issue.  In the case of self-funded plans, insurance companies are only facilitators of the plan, nothing more.  All decisions are made by your employer. I hope I was able to provide assistance to you.

Thank you both for your help.  The policy here is a fully funded policy.  According to the Customer Care department at the insurance company the policy that my company has does not cover any obesity surgery at all.   However the representative at the insurance company who told me to file the appeal said that she thought I had a very strong case since I was told that it was covered and so was the doctors office.  The insurance company should have to pay for it, is what she said, unfortunately she doesn't make the decision, someone else does.

You said: my company has does not cover any obesity surgery Make sure that you, your employer, your doctor's office and your insurance company are all speaking the same language.  Many insurance do not cover "treatment for obesity."   However, if it is deemed medically necessary, the weight loss surgery is covered (but not as a treatment for obesity, you'll be treating your co-morbidities). Talk to your surgeon's office and ask them for the procedure code for the surgery you plan to have.  Then call your insurance company and ask, "Is procedure code ### covered under my insurance plan."   If it's covered, ask them to send you a copy of the requirements you need to meet. Good luck, Pam