Start the old brain working

Ok fellow OH members  sometimes it feels like my brain never stops working.  I have a few questions that have been raised by answers given to other questions. 

If the state of Maryland has a law ( Senate Bill 522) that group health insurance covers treatment for morbid obesity how can it be an exclusion?  Of course there are certain cir****tances that must be met.  If the plan is self funded, if there are less than 50 employees or the federal employees health plans then this law does not apply.  My  company has employees world wide, is not self funded, and is not a federal employer. 

I have been in touch with the California Commission on Insurance and received a call back and was told that the insurance company has put the exclusion on the policy not my employer.
They are sending me the paper work to file a complaint against my insurance company in case of a denial in the first go round.

Yes I am gearing up for a fight as I have done for a long time when dealing with any thing health care.  I learned the hard way that as a patient you have to be your own advocate.  A person must do their research and know what they are talking about.
If you have all the correct information then you have less chance of being screwed.   It is my body. my choice, and I am going to do what I need to in order to make it last as long as possible and work at top performance.    I have spent many many hours searching for information and finding ways for people help me help myself.

I'd like to read the law since i live in Maryland.

do you have a web citation I can see?

Ladybugnessa:  below is an unoffical copy of the law for the state of Maryland and also you can go this link for the Maryland Insurance Administration

www.mdinsurance.state.md.us I hope this helps and if your policy is written in California you can call the Californina Commission on Insurnace. 

I hope this works

If you need anything else or find out anything that may help either of us let me know. 

Hugs

Lori

 

Remember: Never settle for less than you deserve and you deserve nothing but the best.

SENATE BILL 522 Unofficial Copy 2001 Regular Session C3 1lr0385 SB 496/00 - FIN CF 1lr0386 ____________________________________________________________________________________ By: Senators Hoffman and Hollinger, Hollinger, Bromwell, Dorman, Astle, DeGrange, Della, Exum, Hafer, Hooper, Kelley, Roesser, and Teitelbaum Introduced and read first time: February 2, 2001 Assigned to: Finance _____________________________________________________________________________________ Committee Report: Favorable with amendments Senate action: Adopted Read second time: March 21, 2001 _____________________________________________________________________________________ CHAPTER_______ 1 AN ACT concerning 2 Health Insurance - Treatment of Morbid Obesity 3 FOR the purpose of requiring certain insurers, nonprofit health service plans, health 4 maintenance organizations, and managed care organizations, and carriers to 5 provide coverage for the expenses incurred by certain obese patients for certain 6 surgical treatment under certain cir****tances; authorizing certain benefits to 7 be provided through a managed care system; of morbid obesity; requiring the 8 coverage of morbid obesity to be provided to the same extent as for other 9 medically necessary surgical procedures; defining certain terms; providing for 10 the application of this Act; and generally relating to coverage of expenses for 11 surgical treatment of morbid obesity under health insurance. 12 BY adding to 13 Article - Insurance 14 Section 15-837 15 Annotated Code of Maryland 16 (1997 Volume and 2000 Supplement) 17 BY adding to 18 Article - Health - General 19 Section 19-706(rr) 20 Annotated Code of Maryland 21 (2000 Replacement Volume) 2 SENATE BILL 522 1 Preamble 2 WHEREAS, Obesity is a significant health problem affecting hundreds of 3 thousands of Maryland residents; and 4 WHEREAS, Severe or morbid obesity increases the mortality rate more than 5 threefold, causes physical and emotional disability, is often associated with comorbid 6 conditions compounding its adverse impact on longevity and quality of life, and is 7 amenable to established surgical treatment; and 8 WHEREAS, Like other chronic diseases, obesity is caused or aggravated by 9 many factors including genetics, behavior, metabolism, and environment, certain 10 therapeutic interventions can alter its course and severity, and therefore, obesity 11 should be treated for purposes of insurance like other medical conditions; and 12 WHEREAS, Health insurance policies commonly exclude coverage for the 13 treatment of obesity, even when severe or morbid and complicated by comorbid 14 conditions; now, therefore, 15 SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF 16 MARYLAND, That the Laws of Maryland read as follows: 17 Article - Insurance 18 15-837. 19 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS 20 INDICATED. 21 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO 22 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN 23 KILOGRAMS BY THE HEIGHT IN METERS SQUARED. 24 (3) "MANAGED CARE SYSTEM" MEANS A METHOD THAT AN INSURER, 25 NONPROFIT HEALTH SERVICE PLAN, OR HEALTH MAINTENANCE ORGANIZATION 26 USES TO REVIEW AND PREAUTHORIZE A TREATMENT PLAN THAT A HEALTH CARE 27 PRACTITIONER DEVELOPS FOR A COVERED PERSON USING A VARIETY OF COST 28 CONTAINMENT METHODS TO CONTROL UTILIZATION, QUALITY, AND CLAIMS. 29 (4) (3) "MORBID OBESITY" MEANS A BODY MASS INDEX THAT IS: 30 (I) GREATER THAN 40 KILOGRAMS PER METER SQUARED; OR 31 (II) EQUAL TO OR GREATER THAN 35 KILOGRAMS PER METER 32 SQUARED WITH COMORBIDITY OR COEXISTING MEDICAL CONDITIONS, INCLUDING 33 HYPERTENSION, CARDIOPULMONARY CONDITIONS, SLEEP APNEA, OR DIABETES. 34 (B) THIS SECTION APPLIES TO: 3 SENATE BILL 522 1 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE 2 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN 3 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS 4 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 5 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL, 6 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS 7 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND 8 (3) MANAGED CARE ORGANIZATIONS, AS DEFINED IN § 15-101 OF THE 9 HEALTH - GENERAL ARTICLE; AND 10 (4) CARRIERS THAT OFFER HEALTH BENEFIT PLANS UNDER TITLE 15, 11 SUBTITLE 12 OF THE INSURANCE ARTICLE. 12 (C) SUBJECT TO SUBSECTION (E) OF THIS SECTION, AN ENTITY SUBJECT TO 13 THIS SECTION SHALL PROVIDE COVERAGE FOR THE EXPENSES INCURRED BY A 14 PATIENT WITH MORBID OBESITY FOR ESTABLISHED SURGICAL TREATMENT IF: 15 TREATMENT OF MORBID OBESITY THROUGH GASTRIC BYPASS SURGERY OR 16 ANOTHER SURGICAL METHOD THAT IS: 17 (1) RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH AS 18 EFFECTIVE FOR THE LONG-TERM REVERSAL OF MORBID OBESITY; AND 19 (2) CONSISTENT WITH CRITERIA APPROVED BY THE NATIONAL 20 INSTITUTES OF HEALTH. 21 (1) ALL NONSURGICAL MEDICAL THERAPIES, AS DETERMINED BY THE 22 PHYSICIAN, HAVE FAILED; AND 23 (2) THE BODY MASS INDEX OF THE PATIENT EXCEEDS: 24 (I) 40 KILOGRAMS PER METER SQUARED; OR 25 (II) 35 KILOGRAMS PER METER SQUARED IN THE PRESENCE OF 26 HYPERTENSION, DIABETES, HIGH LDL CHOLESTEROL, LOW HDL CHOLESTEROL, 27 HYPERTRIGLYCERIDEMIA, SLEEP-APNEA SYNDROME, OSTEOARTHRITIS, OR OTHER 28 MEDICAL CONDITIONS CONSIDERED BY A PHYSICIAN POTENTIALLY REMEDIABLE BY 29 SIGNIFICANT WEIGHT REDUCTION. 30 (D) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE THE BENEFITS 31 REQUIRED UNDER THIS SECTION TO THE SAME EXTENT AS FOR ANY OTHER 32 MEDICAL CONDITION MEDICALLY NECESSARY SURGICAL PROCEDURES UNDER THE 33 ENROLLEE'S OR INSURED'S CONTRACT OR POLICY WITH THE ENTITY. 34 (E) AN ENTITY SUBJECT TO THIS SECTION MAY PROVIDE THE BENEFITS 35 REQUIRED UNDER THIS SECTION THROUGH A MANAGED CARE SYSTEM. 4 SENATE BILL 522 1 Article - Health - General 2 19-706. 3 (RR) THE PROVISIONS OF § 15-837 OF THE INSURANCE ARTICLE APPLY TO 4 HEALTH MAINTENANCE ORGANIZATIONS. 5 SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 6 policies, contracts, and health benefit plans issued, delivered, or renewed in the State 7 on or after October 1, 2001. 8 SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 9 October 1, 2001.

I see the bill.   but that was from 2001.

the link you gave me is for maryland insurance.  I want to see the actual CURRENT LAW.  

Maybe in 2001 I was not paying attention since i was not interested then.

Personally for me it does not matter. I have federal insurance.

You are correct that companies based in MD that offer health insurance must include coverage of WLS (with the certain exceptions you mentioned, such as very small businesses). However, is your company actually BASED in MD (where are they incorporated?)? If not, I'm not sure the law applies.

  I have found that the policy is written and governed by the state of California.  I am awaiting a package from the California State Commission on Insurance.  I still am not sure who has the final say. The Medical Director of the insurance co or my employer.  I don't see how they can deny medical treatment for a well defined disease.  I would look at as a type of discrimimation.  Will keep you informed as things move along.

I wish you all the luck in the world getting them to overturn this.