Insurance Co denial

Hi Everyone! This week I received news from Dr. Peruginis' office (UMass-Worcester) that my insurance company (United Health Care/HarvardPilgrim) had denied the request for my surgery. I am 5' tall, 220 lbs and have a BMI of 42. I have been a diabetic for 19 years, have high cholesterol and high blood pressure. I take medications for all 3. Their reason for denial was that the plan excludes weight loss surgery. I am currently waiting for the paperwork which will tell me what the process is for filing an appeal. I am READY for the battle! I have my whole life ahead of me to make this work and it will. Has anyone dealt with this carrier previously? Any suggestions as to "buzz" words which will help? Thanks for any assistance! Sue

Hello Sue I have been reading quite a bit about these issues and I am really surprised that Harvard Pilgrim has denied you. My own insurance from NH has an exclusion and I will fight it to the end. If that does not work I will switch to BCBS because they will accept the time you had with your prior insurance and you won't have to wait for the six months as long as you've had insurance for six or more months. Good luck and I honestly hope it'll work for you. I will be praying for you and myself, because I just got a surgery date and am hoping that the'll approve it. Take care, Patty

Patty, Thanks for the response. I spent most of the weekend thinking and writing up my appeal letter. I am sure that it will be revamped more as I think more. I have thought about changing insurance companies should this not go through. I'll keep my chins up for now! Thanks, Sue

I'd contact the State Board of Insurance for Massachusetts. My understanding was that WLS could not be denied in Massachusetts. It cannot hurt to call them and make sure. I know that the case worker for Cigna told me this when I was denied by Cigna. Since it only had to do with the 6 mo supervised diet, I opted to just do it then to fight using the State Board of Insurance. Just a thought and I hope it works for you.

Bunny, Thanks for your info on the State Board. I'll check into that issue today. I work close to the State House so maybe I'll just carry a sign for a day too! I am going to fight this all the way. We all deserve to be healthy! Thanks, Sue

Suzanne, my understanding of insurance is limited, but if your policy has an exclusion for WLS, then that is the "whole package" of insurance that your company chose to offer. Sometimes they will buy a HMO plan and then exclude certain items to save money, for example, This plan costs $500,000, but if the company chooses to exclude WLS, plastic surgery, and appendix removal, the price goes down to $300,000. (this is my understanding, and I may be wrong, and the appendix removal is just an example I pulled out of thin air.) Does that make sense? Good luck in your fight but I would ask the benefits department to make sure that the company hasn't chosen to exclude all WLS for the insurance plans they offer.

Hi K.D., I think your understanding of this insurance issue is right on. I was told by the care coordinator at HPHC that this was a "your employer" decision to exclude the WLS. Well, if my only issue was that I was obese, I would understand it more. But, I have 3 other biggie issues and will just fight them. I have not had a "real" fight for something in a log time. This is giving me another cause to fight for now! Thanks again, Sue

If the insurance doesnt cover WLS surgery for anyone than you are in a pickle. Many people change insurance companies just because of this issue. If you still dont have your original handbook which goes over coverage of policy I would search for on either online or ask for another one so you can read up on there policy for it. But if they do cover it FIGHT for your right to be healthy. Amy

Hi Amy from California, Thanks for the response. I think I am in a pickle but I am going to fight it just the same. Thanks again. Sue

Hi Sue, Thanks for you note earlier. I had my surgery 8/4. To date I have lost about 25 or so pounds. I am extremly sorry to hear of your insurance denial. You keep fighting and don't give up. Even though it has been nearly five weeks since surgery and I have had a couple of days that I wished i hadn't done this, I can say I am not sorry. I am now starting to see the change in me and it feels really good. Keep up your hard work and hopefully you will be drinking carnation instant breakfast before you know it. Good luck, Bobbi