I need some advice

I have a question. My insurance (UHC-HMO Choice) has told me that I have an exclusion in my policy for obesity surgery, but what the clause that they read off to me from their computer is different from what my certificate of coverage says. My question is can I argue based on this and do you think I have a shot of getting approved because of this? The reason I'm asking is because the surgeon I went to see won't even write a pre-determination letter because they are telling him that I have an exclusion and are siting the exclusion they have in their computer.

Robin, you need to know why there is a difference. Has the coverage changed? If not, then your written contract is what would be legally binding. Their computer may just have a proposed change in it, or it is just wrong. Your policy in writing is what governs. Good luck Gary

Hi Gary, As far as I can tell, the insurance policy has not changed. The reason I say this is because the book that I used when I went to see the surgeon was dated effective January 1, 2004. I received a copy of the same identical book from my benefits contact this morning. It has the same information in it as the one I originally had.

When you received the duplicate booklet, is the date the same? I would write a letter to your VP of Human Resources and request any and all addendums or changes to the plan. Also ask if the plan will change as of 1/1/05. Ask for a written response. If it's not in writing - it never happened. When you call an insurance company on the phone, it'**** or miss as far as the information you receive from the customer (no)service rep. My personal experience with UHC has pretty good, but they make mistakes like everyone else. Good luck to you! Roberta

Well, the written book governs. Go by that.