UHC HMO Exclusion Loophole

I have UHC HMO in Texas and I have an employer exclusion in the policy for morbid obesity. I have talk to many many people a UHC and got many different answers about my right to appeal and be covered if medically necessary. I finally talked to the main HR department for my husbands company in LA, they called UHC and this is what they said. Yes, you have an exclusion and when you send your pre-determination it will be denied. Then send in your appeal letter and it will be reviewed for medical necessity and if we deem it medically neccessary then you will be covered because your plan is an HMO and is FULLY INSURED. I hope they are right about this and that I am covered. The catch is that the plan is fully insured, so it is the responsibility of UHC to pay medical claims not the employer. I hope this goes through for me and helps someone else also.

Thanks so much for your info Brandi. I also have UHC, and am facing an exclusion, but going through for my denial anyway. I hope what you found out works. I have my complete package ready to go off after I get my denial letter. Debi.

I have UHC what do you have ready? I haven't received my denial letter, but I want to be ready. Do you have an attorney handling your or are you going at it alone?

I haven't recieved my denial letter, but I have my appeal letter letter ready! My Certificate of coverage in the non-covered and exclusions part read like this, meaning not covered...."Surgical and non-surgical treatment of obesity, exept that non-surgical treatment of morbid obesity is a covered health service when provided by or under the direction of a network physician." It sounds like they just cover non-surgical trtmt of morbid obesity, but no where in there do they say they do not cover surgical trtmt of morbid obesity. I will fight it if I can. What does yours say?

Brandi...I also have an exclusion with UHC. Mine is in Ohio. My surgeon's office submitted for pre-cert and I got a denial as expected. Knowing this would happen, I had contacted Gary V. a couple of months ago and he told me to call him when I got the official denial. I talked to him yesterday and he agreed to take my case now. Here's what he said...that UHC is one of the hardest exclusions to overcome, but since my plan is fully funded (like yours) that means that the contract is between UHC and my husband's company directly and that means that UHC would expect that we would probably sue and they would lose more fighting us in court so they'll probably just cover it. When the plan is self funded, you'd have to sue your employer and most people won't do that to get it covered. Confusing, but it made sense when he explained it and I feel like I have hope. RS

Brandi...I also have an exclusion with UHC. Mine is in Ohio. My surgeon's office submitted for pre-cert and I got a denial as expected. Knowing this would happen, I had contacted Gary V. a couple of months ago and he told me to call him when I got the official denial. I talked to him yesterday and he agreed to take my case now. Here's what he said...that UHC is one of the hardest exclusions to overcome, but since my plan is fully funded (like yours) that means that the contract is between UHC and my husband's company directly and that means that UHC would expect that we would probably sue and they would lose more fighting us in court so they'll probably just cover it. When the plan is self funded, you'd have to sue your employer and most people won't do that to get it covered. Confusing, but it made sense when he explained it and I feel like I have hope. RS

Brandi...I also have an exclusion with UHC. Mine is in Ohio. My surgeon's office submitted for pre-cert and I got a denial as expected. Knowing this would happen, I had contacted Gary V. a couple of months ago and he told me to call him when I got the official denial. I talked to him yesterday and he agreed to take my case now. Here's what he said...that UHC is one of the hardest exclusions to overcome, but since my plan is fully funded (like yours) that means that the contract is between UHC and my husband's company directly and that means that UHC would expect that we would probably sue and they would lose more fighting us in court so they'll probably just cover it. When the plan is self funded, you'd have to sue your employer and most people won't do that to get it covered. Confusing, but it made sense when he explained it and I feel like I have hope. RS

Thank you so much for the info. I have been trying to contact Gary since early last week, but have not got in touch with him yet. That info really makes me feel hopeful. Brandi F