2nd Denial from BCBS of Florida

Just got my 2nd denial from Voluntary Pre-service coverage review from BCBS of FL.  They suck.  I guess my next step (which I found hidden in my policy) is to write to the medical director of BCBS of Fl and ask for an in-depth review of my specific case.  I have been overweight all of my life, and have a BMI of 54.6.  I also suffer from hypertension.  Looks like they would just get the picture that they would probably save a whole lot of money by just covering this flippin surgery.  I'm a little bummed, but I'm not ready to back down now!

What was the reason for denial?

I guess I should've included the reason for the denial !  Sorry - It's an exclusion on my fully-insured policy. 

I also have BCBS of Florida, but haven't submitted for approval yet (have to complete the required six month physician monitored diet). I know that when I first started researching if BCBS would cover the surgery, I found that as of 2005 they wouldn't. However, my employer elected to have it as one of our  benefits.

What was the reason for the denial?

Unfortunately, exclusions are the hardest denial to fight. An exclusion basically means they won't pay for WLS no matter which procedure, no matter if it's medically necessary--your employer chose not to include the WLS benefit as part of their insurance package. Your best bet would be to take it up with the HR department at your company and try to convince them to add the WLS rider (although that's tough since it would likely increase everyone's rates).

Well, I've already gone that route with my HR Director, and here is what he replied:

This policy is a ‘fully-insured’ medical insurance policy issued to the company named above by Blue Cross Blue Shield of FL (BCBSFL) for the benefit of the company’s associated employees.  This policy and all provisions of coverage and exclusions are governed by the laws of the State of Florida as regulated by the Florida Department of Insurance.  BCBSFL provides this policy subject to the terms of the policy form as on file with the FL Dept. of Insurance.  Neither XXXX XXXXX Co. nor BCBSFL have the capability of modifying the terms of the insurance policy as filed for specific individuals nor for specific company considerations.  The policy form as filed with the FL Dept. of Insurance governs all policies issued.

Exclusion are difficult.  Start by getting the exact wording of the exclusion from your insurance companies policy.  Post that here and see what everyone thinks.  The wording has to be specific.

The analogy is something like you paying for minimal auto coverage and having an accident where your car is totaled and is your fault.  You didn't pay for it so no coverage.  Your employer is paying for a cheaper plan that doesn't cover WLS so it is excluded.

One option is to discuss with employer to see is they would consider changing the option in the plan with the new year coming up.  They might not realize WLS is not covered and you might be able to make a case as to why they should.

There is an appeal process so it won't hurt to give it your best shot.

Jim