Can't stop crying :(

Before even going to the seminar I used the surgeon's script to call my insurance company to find out if my plan covered Lap-Band. Justin M. (I also have the call reference #) informed me that it was covered at 90% after my $300 deductible was met, and that the surgeon's office (gave him the Tax ID #) was in-network, that I did not need a referral, and that I need not have it done at a Center of Excellence.

I went for all those preliminary evals and testing, and I am scheduled to have an EGD on Thursday. I paid OVER $600 already. Today I call to check my deductible amount because I knew it had changed in the last day or two and I wanted to make sure I had all the info in hand when I went for the EGD. They inform me that my policy DOESNOT cover WLS. I had the insurance coordinator at the surgeon's office call and verify (which they already did due to the diet requirement being unclear and were originally given the same answer as me), and they told her that the surgery was indeed not covered.

Am I out that money forever? Or can I get all or part of it back, considering incorrect info from the insurance company caused me to lose it? Or can I convince them that since they gave me the wrong info, they should go ahead and cover the surgery? Who do I contact to find out my options? I am so mad! I am glad I found out today, instead of waiting until Thursday when I am supposed to pay almost $500 for the EGD.

I went thru the same issues with my surgery! You need to call and ask to speak to a supervisor. Everytime I called my insurance, I got a different answer and after I had my surgery I got a bill saying it wasn't covered! So then I had to call, and have my surgeon call and we finally got it straightened out. If you were originally told one thing and know just who told you that and the reference number, you need to call and talk to someone with AUTHORITY! He didn't just pull out of his behind the fact that you have to have it at a center of Excellence. There has to be some verbage in your policy that he was reading. My surgeon had to submit paperwork before they received the approval from insurance because I had to meet certain criteria. Did yours do that? I don't think they can tell you it is approved until all of the is received.

And to answer your last question, no you can't get your money back. Those are tests that a physician ordered for you to have. Once you have had the procedures done, you can't be reimbursed whether the surgery happens or not!

I feel so bad for you ! I also would call back and ask to speak to someone in authority and explain everything and go from there.I would bring up why they allowed you to have these expensive tests done if the surgery was not available. Costing you money ! Also you say your deductable changed in the last few days ....is it possible that this is also when they stopped covering WLS? If so if you were already in the process they may indeed have to cover it. Also call your ins coordinator at the surgeons office and ask what your options are. If the ins co does not cover WLS there will be little you can do most likely w/o getting a lawyer and that would cost alot. Your other options maybe self pay thru a loan or credit cards or even 401K deductions.Dunno if that is the route you wanna or can go.It gets expensive with all the tests and after care. You might could look into private ins. ? I know that would be costly too. Geez I am sorry you are dealing with this.:(

Speak to the manager at the ins. co. and tell him/her if it is not resolved that you will be contacting your state insurance commissioner's office.

I'm sorry you are going through this! The only other person I can think of you contacting is your state Attorney General's office. They can help sometimes. However, if your policy changed and you didn't have a prior auth.....unfortunately, despite the problem of obesity growing in our country many insurance policies are dropping WLS. Good luck! K

Thanks everyone! I have gotten more info after SEVERAL more phone calls. I think I may just be SOL, as my employer changed the plan on March 1st, so when I called the insurance company on February 21st, the change had not yet been made. So I paid all that money for nothing, I think. I hinted to my HR dept. that maybe they could give me an exception since I began the process BEFORE the policy was changed, but so far I have gotten no response. I printed the policy dated Jan 1, 2011, and it states: "This Plan does not cover any expensees incurred for services, supplies, medical care or treatment relating to, arising out of, or given in connection with, the following: [...] Weight reduction or control (unless there is a diagnosis of morbid obesity)."

I told the insurance rep what page I found that on and everything and she asked for the date of the policy and stated she had a revision stating that it was not covered as of March 1st. Grrrrr!!! I am getting a call back from the supervisor at my insurance company tomorrow supposedly, and I am still unsure as to whether I should go ahead with everything and submit it for predetermination and then appeal the inevitable denial, or if I should just give up.

 
You can appeal it but if it is no longer covered they aren't going to pay for it.  It is up to your employer and not the ins co if you have WLS benefits.  If your employer is no longer paying the additional premium then you just don't have coverage.

I will tell you that you do NOT want to self pay for a band.  It gets very expensive long term.  If you need a port fixed or kinked tubing fixed, or anything you will be self pay for another surgery type. Bands are very expensive to maintain and if ins won't pay to have it placed then they won't pay for all the maintenance and future surgeries.

Your best bet is to talk to your employer and beg on bended knee that the pay the premiums next year when the contract is up for renewal.

I would also ask the HR rep, why you weren't  notified.  Also, are you paying a reduced premium now that you have less coverage?  Also what else did they cut??

Sounds wrong to me that they can just up and change things in the middle of the plan year and not during open enrollment when you have a choice too.

Best of luck to you!

 
Their plan year may well well be from 3/1 - 2/28.

Good point!