Denied a 2nd time

I've been denied 2 times now for wls, I have IBA Health Plan and am in Michigan. The 1st time I went to the IBA offices for a formal appeal. Then the 2nd I sent a packet to the external review board in Lansing. I got a call on my cellphone at 3:30 pm today, it was the state external review board, they have turned my gps request down too. They say IBA is a commercial insurance company. and not like BC/BS insurance, not an HMO, so they aren't required to certify with the state board like other insurances. There is nothing left I can do they say, unless I switch insurance companies, and that ain't happening. My hubbys' boss isn't going to switch. I'm not sure going to court would even work, and it's not like we have the cash to waste. But I guess I need to sit back and think on this a bit. Any suggestions? Thanks for listenin, Cynthia

Cynthia, It sounds like your plan is self funded, which means your employer sets the rules. Can you talk to HR Dept about making some changes and covering the surgery? Also, were the deadlines met by IBA? If self funded they only have 60 days to decide. And if you know of anyone else they allowed to have the surgery you can argue both the missed deadline and arbitrary allowance of benefits to the social security administration, (EBSA), may help. Good luck Gary Viscio obesitylawyers.com

Hello Gary, I apperciate your response! My husband believes that it is self-funded, the insurance company, over the phone suggested we talk to the HR person and ask if they would change the policy. My husband has spoken to the HR Department. The HR person says that he didn't think the owner of the company would change it. (I used to work for the same company at one time, and didn't leave on good terms with the owner. I wouldn't stand for the bullying he was giving me and he didn't like it and fired me. So, I can safely say the owner won't change the policy.) And, from the time I was denied, via phone, to having my appeal hearing at their offices, it was well within the 60 days guideline. As far as anyone else having had this surgery and IBA approving it, I did find one person on OH, that was approved by IBA after 2 denials. It was in 2002 I believe. She lives only 12 miles from me, I emailed her thru her profile page twice and received no response, so that was a bust too. Pardon my ignorance, but I don't know what... "arbitrary allowance of benefits to the social security administration, (EBSA), " is Thanks, Cynthia

I wonder if you could talk to the State of Michigan Attorney General's office and make a complaint against them?

Cynthia, You didn't mention why you were denied. Can you give us some more information? Roberta

opps! Sorry! It is a written exclusion in the policy booklet, but I went thru with the consult at the Barix in Ypsi, because Barix said they usually have no problems, even if there is a written exclusion policy. Cynthia

Written exclusions are very difficult to get around. Depending on your personal medical condition, I would suggest that you make a cost analysis showing the cost of managing your co-morbidities vs. WLS. It's all about the almighty dollar, bottom line. Fight the good fight! Roberta

Hi Roberta, I did that too, but only on the external review appeal, ( I had no idea what to do for my first appeal letter ) in hindsite that first letter was a flop! But the 2nd letter to the review board, I showed the costs and it wasn't even looked at, the state review board didn't even look at my documentation she said, because IBA is a "commercial" insurance and not subject to the same certifications as say, BCBS insurance. ( no ideas what exactaly that means ) So they couldn't help me. At this point I'm not even sure Gary could help me. But I'll be reading his appeal package that was emailed to me and see what it say's. I just feel, in my heart, at this weight, time is running out for me, not options wise but life wise! Thanks for the ideas, I'll keep trying. Cynthia