Can you appeal an exclusion?

I have United Healthcare Choice Plus and I'm in Florida.  Under my benefits it says...

Obesity            Both In/ Out of Network
                        EXCLUSIONS
                        -Surgical and nonsurgical treatment of obesity, including morbid obesity


Can I fight this in any way?


Thanks,

Autumn

You can appeal but it won't do the least bit of good.  You haven't paid premiums for WLS so you have no coverage.

WLS benefits require an additional premium.  It's like having homeowners insurance and no car ins.  If you get in an auto accident your homeowners isn't going to pay it even though you reallllllly need them to.

Welcome to the world of self pay. :o(

Hi MidwesternGirl,

Thanks for the reply.  I wasn't sure who could and couldn't appeal and wanted to make sure before I gave up on the insurance and went on with the plan for self-pay. I'm going to use your example to explain it to my family if you don't mind.  By the way, how are you liking your sleeve?

I love my sleeve, can't imagine life today without it!  Best thing I ever did and best money I ever spent.

Love the enthusiasm :-)

It's just so easy, problem and maintenance free.  Have surgery and you are just plain done!

Autumn,
If you currently have insurance with your employer - I strongly suggest you start a "campaign" with your HR dept. on WHY it is important to add bariatric coverage.  Get some co-workers involved and really PUSH the issue.  It might not be helpful to you NOW -- it may be helpful in the future for you &/or others.
Just a thought,
Nicki

Hey Nicki,

Thanks for the reply.  Actually, I'm not working right now.  I'm in nursing school full time, and am still insured under my parents' plan.  However, thats a great idea for those who are insured with their employer.  It could really make a difference!

Autumn

Autumn if its an exclusion they are hard to fight, however if the company is a self insured policy you have the option to appeal

If You Have an Employer’s Self-insured Medical Benefits Plan

The denial probably will occur at the predetermination stage of the process; therefore, you may not receive a formal Explanation of Benefit (EOB) form from the provider denying the authorization. In order to submit an appeal, you must receive a formal written denial, usually in the form of an EOB. This EOB should include a paragraph explaining your appeal rights and how to submit an appeal. Such as:

If you do not agree with this determination, you may appeal it in writing to the Pension and Benefits Appeals Board within 60 days of receiving this letter. In addition, you have the right to appear personally before the Board, review pertinent documents, submit issues and arguments in writing, have a representative appear before the Board or present written issues and arguments, and present additional information to the Board.

The denial should also give you a detailed explanation why you were denied, and what specific sections of the plan were used to make the denial.

Do not be afraid to contact the provider to request the details of your denial. Also, if you have studied your plan and feel there is a specific portion of the plan that allows for the treatment, you should ask them to review your denial with this in mind. Many times an insurance company applies the rules they have for their insured products and not the plan rules for the specific employer when making initial determinations.

The laws and regulations that allow a company to get tax advantages for providing employees with medical benefits also require the plan to implement an appeal process. A verbal denial, such as the plan does not cover this procedure, does not meet these regulations. If you cannot get a formal denial from the provider, contact your employer’s personnel or benefit department for a formal denial. At the most, the plan must respond to your claim within 60 days or they may not be in compliance with ERISA.

Once you have received the denial, you should submit your appeal paying close attention to any time limits required by the process. This may sound like a lot of work, but in the end the benefits to your health are worth it.

Avoiding Discouragement

The process of contacting and working with your insurance provider may be a frustrating one. Do not become discouraged. By taking your time with each step and maintaining patience, you will only enhance your ability to have your treatment option covered by your insurance. Remember your rights as a policy holder. Do not be afraid to ask questions and do not forget, as we mentioned before, that you pay for your insurance, so make them work for it!

Statistics to Include in Your Appeal Letter

These statistics briefly detail morbid obesity and its affects in the United States. Feel free to use these statistics when writing your letter(s) to your insurance provider. Educate them on the affects this disease has not only on you and your quality of life, but also others.

• It is estimated that more than eight million Americans are morbidly obese. Morbid obesity is characterized by an individual weighing more than 100 pounds over their ideal body weight, or having a body mass index (BMI) of 40 or higher.

• Approximately 75 percent of the morbidly obese have at least one co-morbid condition (diabetes, hypertension, sleep apnea, etc.) which significantly increases the risk of premature death.1

• Life expectancy for a 20 year-old morbidly obese male is 13 years shorter than a normal weight male of the same age.2

• Annual direct medical expenditures attributable to obesity are $147 billion.3

If you need some help let me know

Hi Vicki,

Thanks for the wealth of information :-).  I'll be going to the surgeon's office for my first consultation soon, and I'm going to try to get a meeting with the insurance specialist.  I have to admit, most of this is going over my head. 

Question, if I wanted to begin the appeal process at what point would I do that.  When I go for my initial consultation I'll be paying out of pocket since my insurance says they don't cover it, right?

Thanks for your help,

Autumn