Interesting Insurance Dilema

A little background first. I had a RNY in Utah in 1998 after 3 years of denials from 3 different insurance companies...(my work kept changing carriers). In fact, I had spent one entire year jumping through hoops and going to one of the insurance companies monitored nutrition class, etc.....just so my company could switch carriers right as I was about to get my final approval.  I was 402lbs with diagnosed sleep apnea, high blood pressure and mobility problems so I definitely fit the criteria of morbid obesity. Finally, frustrated beyond belief, I gave up the fight and I emptied my 401K on a hardship loan and traveled the eight hour car trip to Utah and had my surgery. Skip to now, over 9 years later and I weight 302. My weight loss stalled around 245 and was stable for about five years. Recently it started coming back up again and I started with the yoyo dieting which just made things worse. My sleep apnea and high blood pressure have returned, etc. Anyway (sorry for the long post) ....I decided to seek a revision. I called my benefits coordinator at work first to find out the companies insurance status for wieght loss surgery. She told me she would contact our representative at BCBSFL and find out.  She sent me an email back that stated that it was covered, but only through the end of 2007 under medical nessecity. So I busted my chops and got my op report from Utah and did everything at warp speed so I could get the approval and have the procedure this year.  Then I get a call from the Dr's office and BCBSFL says I have an exclusion and no coverage for this. I call them and they tell me the same and that whoever told my benefits coordinator that it was covered was wrong..... I am SO ANGRY!!! Does anyone find this link ironic?

http://www.bcbs.com/news/wellness/weight-loss-surgery-saves- lives-studies-find.html

OMG!!! This just happened to me. I asked in Feb. and got an email from CIGNA themselves and now that i have a surgery date they said its not included in your plan. Well i was told it was by my HR Dept and Cigna. I'm wondering if i have a legal issue, maybe that i need to talk to a lawyer or something.

Amazing, isn't it?  I am going to fight them on this. I already told my plan administrator that I was going to take this as far as I can possibly take it.  It all comes down to dollars. It always has. It always will. I tried to make the argument with one of my past insurance companies a decade ago that this surgery would save them money in the long run by reducing or alleviating my co-morbitidies and I was told (off the record of course), that most folks in the morbidly obese category would die before they (the insurance company) hit the break even point on the surgery. If I were you, I would definitely keep that e-mail.  Keep in touch and I will let you know how things work out. over the long haul.

I just got off the phone with them again they said i can't do anything about it, they were going to email  my company rep to let her know whats going on. Well that company rep better have some answers because i won't drop it. Are you kidding, the bills keep piling up, there going to pay for this. My only issue right now is, where do we go from here? Who do we complain too? Do we hire a lawyer? We can't appeal because she said if they don't offer it than we can't appeal, there's something wrong with this system.

That is because we have "exclusions".  They won't pay come hell or high water. Your best bet is tossing it back to your benefits administrator in HR. I am bombarding HR with information to support the need for this surgery.  In fact, before my company switched to BCBSFL, they DID cover this surgery. One of my employees had a RNY in 2003 or 2004 and she is doing great.  Enter $$$ again. I am still going to put in appeal paperwork with the Insurance company. If nothing else, doing everything I can to consistently annoy them gives me a bit of mental relief.  The BCBSFL exclusion of this surgery is in opposition to thier own position statement regarding appropriate treatment of clinically severe (morbid) obesity. I called them today again and told them I plan on doing everything on their lengthy appeals process...And step one was making that phone call per the directions on thier website. fight fight fight....go over thier website looking for info...google everything you can on them.  Read the benefits booklet carefully. Talk to folks who have been approved by them to see how and under what cir****tance. I am a firm believer that this coverage should be mandated nationwide.  Insurance companies should not be allowed to second guess the National Institutes of Health and a myriad of other professionals who say this is the correct and appropriate treatment of this disease.

****UPDATE***** Here's where i am with this. I went to my HR and she went back to our insurance broker. Anyway after numerous emails and all day today going back and forth with these two people (there suppose to be on the customer side) i freaked out on the both of them. I have learned that because i saved that email from Feb. 07, NJ has a NJ Insurance Board, and after me reading there web site they love Cigna (NOT). They imposed a fine of (I think) it said 9 million dollars on Cigna for changing small businesses insurances and not letting the SB know all there options while picking the insurance. This board is there for the people and you can file a complaint with them and they will let you know if you win your appeal and then Cigna will be ordered to pay. Anyway I am going to receive an apology letter from the Cigna rep because she made a mistake. HAHA Not good enough!!! Now after telling our insurance Rep that he is suppose to help me and not Cigna has he agreed to file an appeal with Cigna. Well at the same time i am going over there heads and still filing the complaint. So this is for anyone out there that read my info and didn't know what to do, Always keep your paperwork. Check your state government to see if any state mandates the insurance company to offer to you. There are states out there that mandate the insurance companies to offer WLS under medically neccessary claus. So look up the state government website and do all your research. I will update what happens next. Thanks for listening and allowing me to vent.

AWESOME!!! You go girl. GO GO GO!!!

UPDATE: I got an email today from my benefits adminstrator in HR. It was a forward of an email from BCBSFL. Apparently my company DOES have coverage under medical necessity after all. But only on the 2007 plan. 2008's plan does have an exlusion...... Hmmmm....It will be interesting to see how difficult it is from here on out to get the BCBSFL approval now, especially since they re-iterated how I would have to have the procedure by the end of this calendar year. Can anyone out there who has had a revision done through BCBSFL tell me how difficult the approval process was with them? I do have someone who said she would try to expedite the process internally, but now my fear is how many paperwork hoops are they going to impose????