Is it a matter of opinion or interpretation??

Going through what I am at this point with UHC I have decided to see what others think on a few things.  Feel free to post your opinion, advise, or comments on this issue.  I have stated what the letters say I have recieved and my opinions, interpretations of the situation.  I am just curious to see what others have to say.

1)  UHC states that they are regulated strictly by federal and state laws when administering the contract of health care.
How ever they also say that the case law that I submitted is not applicable.
My response:

If they are bound by state and federal laws then should they not honor the laws of state were I reside? 

2) They do not deny the medical necessity of the wls i am seeking, however they can not authorize, reimburse or agree to pay for it as it a non covered service as per the exclusions of the policy.  If they agree to the medical necessity but deny paying the claim is that not a Medical Decision? However they also say that treatment decissions are between me and my physician.  Ok is this double talk to confuse me?
My response:  If something is deemed medically necessasry then denied is that not the making of a treatment decission and taking that decission out of the hands of the patient and the physician?
3)  First response to appeal sends me contacting the state of Maryland Attourny General and Maryland Department of Insurance, for assistance.  Second letter after first appeal sends me to California Department of Insurance for Independent Medical review. 
My response:  I have contacted the Maryland Education and Advocacy Unit, and the California Department of Insurance for an independent medical review.

I figure if they realize that I am not going to go away and I keep at them that I may just get what I need.


Just a few thoughts for the day and something to get a discussion going.


Zells_lori is'abuddingrose'

Lori,

We are in pretty much the same shoes (my policy was written in VA, yours in CA, but we both live in MD, and both our companies have exclusions for WLS in their insurance policy) - but I am taking a different tactic.

It's not UHC's failure to cover my procedure - it's my COMPANY'S failure to include WLS coverage in our policy that is the showstopper.  The company doesn't pay the premium for WLS - so of course UHC won't cover it.

My understanding is: first I have to get a waiver to the exclusion policy from my company - then UHC will make a determination, based upon the information submitted by my doctor.

Can you point me to the case law you've quoted??  I spent HOURS working on my letter requesting a waiver last night... it's getting close - I plan to submit it on Monday.

Thanks!

Sheri

Jones v. Durham Life Ins. Co., 966 F.2d 1442 (4th Cir. 1992);
Holloway v. J.C. Penney Life Ins. Co., 190 F.3d 838 (7th Cir. 1999);
Essex Ins. Co. v. Zota, ___ F.Supp.2d _____, WL959917 (SD Fla, April 8, 2009);
England v. John Alden Life Ins. Co., 846 F.Supp. 798 (WD Mo. 1994).

These are the case laws that I used.


Do you mind sharing information on the waiver that you mentioned.

Who told you get it?  How are you supposed to obtain it?  If you get then will UHC pay for the surgery?

sharing information is critical for patients like us.

Zells_lori is'abuddingrose'

Hi, Lori,

I first heard about a waiver from Dr. Averbach's office in Baltimore. I also read about it here on OH and on http://obesitylaw.com.  I then contacted UHC, and got the info I posted above: their hands are tied.  Specifically:

"There is no provision in your company's policy for WLS."

However, I did confirm with the rep that a waiver to the exclusion is possible (albeit unlikely, in her opinion).

Bottom line - I believe it's useless to approach UHC for approval until I've gotten approval - in the form of a written waiver or exception to the policy - from my company. I've already discussed this with the HR director. She was not promising... which is why I'm putting together a formal letter with a lot of documentation.

What I'm NOT doing is getting letters of medical necessity from doctors. Haven't decided if that would help my case with the company, or not. 

I do have a worry, tho: Maryland is an "at-will" State, meaning I can be terminated any time, for any reason.  If I rock the boat too much by asking for this exception... will that jeopardize my job??? Decisions, decisions.

What do you think (about the waiver/process, not about the risk of losing my job!!!)??

Sheri

I am currently waiting for the case worker to get back to me on my particular case.
I did mention to him about what we had discussed here briefly.  The only thing the case worker said was to wait to hear from him either today or tomorrow because he had to return a call to Minesota UHC headquarters. 

I would /will use what ever I need to inorder to get what I need. Letters of medical necessity can be saved till needed.
Also I have the same worry about employment if I go to HR and ask for something like a waiver. 

I currently have a 4 inch notebook of information and gathering more.

The only thing I can really say at this point is good luck to us both and may we be victorious in getting what we need.


The worst that can happen is at this point
is i get laid off and have to get state insurance which may cover wls. or stay employed and when it comes time for the company to negotiate for new coverage remind them about the wls exclusion being lifted. 

It all comes down to wait and see i suppose.

The issue is that your employer chose to exclude WLS from your insurance coverage.  They chose not to pay the premiums to include WLS.  It doesn't matter if it's medically necessary or not, the plan you bought does not include WLS.  They aren't going to pay for it because you haven't paid for that benefit. 

Kelly