new here and insurance excludes obesity related items

juliemomto2
on 6/6/08 4:55 am

OK, I need to know if this is a battle that I can win...feeling like it might not be.  I have United Healthcare (Choice Plus), the policy is through my employer, but my "employer" is a benefits administrator called Administaff.  So I don't "know" the people there, they simply provide health insurance, payroll services, etc. to my true employer.  To complicate things further, I don't know anyone at my "own" company as I am a remote employee and was hired on there in a merger type situation.  AND I am getting ready to go on COBRA, lol.  Twisted enough? Here is the wording of my insurance policy, under exclusions it contains: 9. Surgical and non-surgical treatment of obesity, including morbid obesity. This is a choice the "employer" (Administaff) has made, as I understand it.  Since I am leaving (we are un-merging and I will be an independent contractor/self-employed) AND I know no one, I have NO pull on the employer side of things. When it is specifically EXCLUDED in the policy, if you submit a predetermination, I assume the answer is always no?  Any advice/ideas? I don't have the money for self-pay but considering finding a way...just don't know whether this is a fight worth even taking up on the insurance side.  My husband is a stay-at-home dad, so COBRA will be my only insurance choice until it runs out and I go on the state high-risk insurance.   My BMI is 42.5 and I have hypertension, diabetes, and GERD.  Have been overweight all my adult life and just keep creeping up the scale.  I have not gained and lost weight over and over but after having each child I did get down somewhat and creep back up.  So not a yo-yo dieter really, and no "documented" diet history either. Sorry this is so long.... Julie, age 37

talksoupslp
on 6/6/08 11:07 am
I say start the process and fight it.  I work for the school system here in Georgia.  And the state of Georgia, in it's infinite wisdom, has also excluded it.  I have started the process for surgery and think so far that the psych visit will be covered (if we don't say it's specifically for bariatric surgery...I'm "depressed over my weight" as far as insurance knows), and the pre-op testing has a different diagnosis than obesity so it should be covered. Once everything is done (including 4 letters from 4 of my docs indicating medical necessity), I will submit it to insurance.  Once I get a denial, I will hire an attorney.  If people don't fight, the policies won't change.  So personally, I say go ahead and fight.   And you might want to start documenting some diet history... Good luck! Elli
juliemomto2
on 6/11/08 1:24 am
Thanks!
Stephanie C.
on 6/10/08 1:52 pm - Chicago, IL
Hi Julie,

We have many similar cir****tances with regard to our insurance situations.

Some of the best info I received on employer administered plans came from Paul. He has all the info on his website under "Self - insured (ERISA) employer exclusions". I have a new insurance policy now that doesn't contain any "discriminating" exclusions. Prior to that I paid a lot of money for COBRA benefits that were through my employer and contained a bariatric surgery exclusion. They excluded anything weight loss related - how helpful in a time when they are calling obesity an epidemic, right? Best, Sam

You see things; and you say 'Why?' 
But I dream things that never were; and I say 'Why not?'

- George Bernard Shaw
juliemomto2
on 6/11/08 1:27 am
Well that is the thing - if I smoke and get lung cancer, that is covered, but if I want to get healthier it is NOT.  You have such a good point about the epidemic!  Thanks!
gary viscio
on 6/10/08 11:30 pm - Oceanside, NY
RNY on 07/01/03 with
I would go with talking to your employer, they may cut you some slack
Gary Viscio
www.ObesityLawyers.Com
RNY 7/1/03  -166lbs
juliemomto2
on 6/11/08 1:30 am
Well, the thing is - I am no longer going to be an employee after July 1st.  I have an odd situation, I was an independent contractor who lucked into being an employee with benefits for a while and now am back to contracting.  So this employer frankly will not care. In that case, do you think just going self-pay is the wisest choice?  The good side it I can get the ball ROLLING and get it done.....silver lining...   :-)
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