United Healthcare trauma

Although my doctors have listed RNY surgery as Medically Necessary, My insurance is denying my claim due to a exclusion clause. Treatment for Obesity including surgery is not covered. I have several co-morbidities such as insulin resistance, hypertension, secondary hypothyroidism, sleep apnea to name a few which my insurance is suppose to cover. I'm on over 200 dollars worth of medication (and that is with my co-pay). The only explaination of not covering this treatment is "We will not pay for benefits not covered for exclusions even if recommended by your physician and is the only available treatment for your condition." They went on to say, "federal and state laws (I live in Florida) require UnitedHealthcare to strictly administer the terms of your health benefit plan. We may not deviate from the plan terms of your Benefit Plan." My HR department has stated that they will not change the policy to include this benefit, but they did ask me if I had appealed. Does anyone have any suggestions for me? I'm at a loss.

Dont have any suggestions but I will be watching this post to see if anyone replies. My daughter is under my husbands insurance and he has UHC also and WLS of any kind is excluded. I am going to switch her over to my insurance in another year so that she can get the surgery. You may have to start looking at other options if they wont pay for it. Dr Aceves in Mexico charges around $11,000.00 for the RNY.

I have read some articles that state exclusions can be overcome due to the covered things such as hypertension, sleep apnea, etc. However, I don't know how they did it. I hope some people on here can give some good advice.

I too don't know how to overcome this obstacle. I know it will be an issue for me too, because my husband went through this when he had his done, and we ended up financing his. I would love to see if anyone has a solution!

I would call and find out what the appeal process is. Since they've already asked you about the appeal process, I am thinking that may be your only route for getting it covered. It also may just be a State of FL thing too.

Good luck!
Brenda~

I also have UHC insurance through my employer that I have paid premiums on for 10 years and they have done the same thing. I work for a small company with 45 employees (world-wide) and I just happen to be the only one that is morbidly obese and in need of WLS.
Not unlike most, they have negotiated the exclusion from coverage for "WLS, Weight Management Programs of any kind, and Doctor -Supervised Diets, even if medically necessary, for morbid obesity - for any reason," to "keep the premiums as low as possible for everyone."
I have found out that this "exclusion-language" is pretty much rock-solid and I'm unable to get my surgery covered with insurance, in any way, because of it.
I've spoken to several patient advocates, their consensis is the same. It truly sucks!

I have gone to my company executives and asked for them to change our insurance coverage, so I have a chance to get healthy thereby costing less in medical expenses for both them and I, but the response was a resounding "No, not gonna happen."
So I even went so far as to ask the president of the company if he would consider authorizing financial assistance from the company to help me pay for the surgery, since their negotiations have prevented my coverage. That question got the same response.

It's difficult, depressing and debilitating, to say the least, when you have to deal with people whom have the audacity to think they have the right to make life-altering decisions for you, pertaining to your health, even though they know nothing about your life and the health conditions that you struggle with daily. I feel greatly discriminated against because of this, but also because almost everyone I work with thinks that WLS is a cop-out, a lazy person's answer to loosing weight. This attitude is one of the reasons why we obese people have so many problems with very prevalent discrimination in society.

I found a petition on one of the ObesityHelp blogs that is asking the government to force insurance companies to include WLS surgery in their coverage for morbid obesity. It's short, but to the point. It says that we should not be denied treatment of any kind for our obesity disease when the law provides for drug and alcohol addicts the same protection of coverage as we are asking for.

I would encourage you to seek and find that petition and sign it. And I encourage you to petition in any and all other ways possible to get the coverage you need. But please don't let the negative responses discourage your efforts. I am not letting them stop me and I hope we both will find a way to achieve the necessary financing we need without having to resort to putting ourselves in harms ways to do it.

Good luck! = ; }