GHP

I posted these questions on a thread below, but wanted to get them out again in case they were missed. I have filed second appeal with GHP (they still denied as experimental, despite a ton of information I sent them showing otherwise). They called within a day or so and told me they would need a 3 month dr supervised diet in the past six months and several specialist visits before they could even consider my surgery. I could have had the diet thing almost done by now had they told me up front - I think it's just another bogus stall tactic anyway, as they have all my diet history for the past 20+ years plus 2 years of medical records recording my weight at the doctor's office, with 30 pound fluctuations that I think show my attempts to lose weight. My doctor has, on several occasions when we have discussed my weight problems, given me dietary information (like the food pyramid and the diabetic diet, etc., all of which I know from years and years of trying, plus I know they don't work for me, so it's a waste of his time and mine to have me come in every week or two for his "supervision"). They also want the psych and a pulmonary exam done and say they would need this for approval, but I was told back in October that they would not pay for any specialists until after approval, so I had canceled all this after having it set up. Do you think this means they are realizing their "experimental" defense is not going to hold up, so they are looking for other things. They really would not have to, as they have already ensured that I can't get the surgery before the end of the year, but I guess they want to be sure. I have filed a complaint with Dept of Insurance. They also scheduled a hearing for 12/22, two hours from home, which is going to be difficult if not impossible for me to attend. If I don't, does this blow my appeal totally? The woman who called said I didn't have to, that she would present my case if I could not be there, but it would seem that she would not help my case too much. Can I ask them to reschedule, or does that hurt me too? Can I write another letter just for that hearing to point out the things in my information that I feel really support my position? I don't know what to do on this. I have asked in the appeal to them and the one to the Ins Dept that they be required to provide the surgery in the new year. The Insurance Dept said they probably won't even get to review it for 20 days. Any advice would be appreciated.

First, read your Summary Plan Description booklet carefully. Is this an ERISA plan? Your denial letter should be consistent with what you are being told on the phone. If you have a letter denying WLS as experimental (is this RNY, DS, or lap band) they can't come up with new and interesting ways to deny you in addition to the experimental "non-reason." Mention this to the Insurance Commissioner and also during your hearing. I would call them today and tell them: 1. you want to participate in the hearing next week by teleconference. If you have the opportunity to go in person, I would certainly urge you to do so, because you will make more of an impression in person, than on the phone. You are your own best advocate. Don't let anyone else do it for you. Fight the good fight! Roberta

Roberta, Thank you for the help. I am going to try my best to get there, although it will be tough to get away and I will have to take an entire day off from my job. I have two new studies that I have found since I sent my appeal and would like to reference them at this hearing. Do I have to send them to them first, or can I bring them with me? Can I provide some sort of "handout" that contains the high points of my appeal, since I have sent them a great deal of information? I have never been involved in a hearing, so don't know what is permissible. I send letters to social service clients about hearings in my current job, and these always say that they have the right to bring witnesses and present evidence. Are these hearings like that? Also, I have asked this several times and no one seems to have an answer - am I within my rights to ask them to provide the surgery in the new year and is there any chance I will get that done at all? At some point, someone mentioned that they might have to go back to the date of the denial if it is overturned and pay as if it had been approved then. Or is that something I would end up having to take legal action to try to get? I know you can't give a definitive answer, but would appreciate an honest opinion. Also, do you know whether this could be considered to be "utilization review". Again, I would not hold you to anything - just curious as to what your experience tells you, as you seem to be very knowledgable. Last question - I have found another person who seems to be going through almost exactly the same experience with GHP and state insurance and has gotten the same runaround (though they appear to have just given up on it). Would it help to bring this up (showing a pattern by GHP) or hurt (they could say they treat everyone the same). Just thinking which way this might play. Thanks again.

JH, There is nothing more important than being at the hearing, certainly not a job. Jobs come and go. I guarentee you that there is no company loyalty towards employees in this day and age. You must take care of yourself, because no one else will, and your life depends on it. You can certainly bring a handout with your main points. This is not an administrative hearing like the ones you are used to attending. There are no rules of procedure. You will probably be given a very short time (10 minutes or so) to go over the salient points of your appeal. Stick to your past diet history, and your medical condition. Don't worry about "teaching" them about the miracle of WLS. They already know it will improve your health. You need to focus on why you should be approved, and why you are eligible for benefits under your plan. Wait for an approval before you tackle getting them to pay for surgery in 2005. If you are insured under your employer (self insured) you may have to approach this with your employer when you are approved. If the denial was in error, and you should have been approved with your initial submission, you shouldn't have a problem getting surgery next year. It is unreasonable to think you could even get a date before the end of the year. I don't think you'll need an attorney. First things first. Get approved. I would not mention the other person in your hearing. Keep focused on your issues - eligibility for benefits. Fight the good fight! Roberta

Thank you for the information. I plan to make every effort to attend the hearing, and I want to make the most of my time, so I will have something to give them to hit the high points. I am pretty certain that GHP is not self-insured, at least the person at the state insurance plan told me she did not think so (some of the plans apparently are and some aren't, and I needed to know in order to file my complaint with the state dept of ins). My main concern about the new year is that GHP is not a carrier for the state after the end of the year, so I don't know if they can just walk away and say it's not their problem, even if I get the approval. The state plan won't have too much leverage since the contract will have expired (plus the state has allowed the exclusion in the new year, so they aren't exactly friendly to the surgery). The second concern is that I had to choose a new carrier (UHC) and now my doctor does not accept them, so that's a whole other issue. Even if I could fight the new exclusion, I would probably have to travel several hours to get the surgery, when I had a doctor close by who I really liked. I know there isn't any way to get it done in the current plan year. I feel fairly confident that GHP will have to admit that I should have been approved, I just don't know if it will do me any good after the fact.