I Am Still Fat

For anyone who has been following along I still have no decision 11 days after United Health Care reversed its decision to cover my procedure two days prior to surgery.  Three lawyers have denied the case not enough money in it for them.  They want me to be dead first I guess.  I have written the appeals letters, contacted the company, threatened to sue.  The last word I got was they are trying to figure out why I was allowed to appeal in the first place.   It appears they are trying every method of ensuring they do not pay for surgery.   I have requested a written answer by end of business tomorrow or else.  Or else I get to wait until they are damn good and ready to do what ever the hell they want.  What a joke.

Davo-I have been following your posts, and my friend have you tried Gary Viscio? This is what he does , "his specialty". Hear is his link hear on OH http://www.obesityhelp.com/member/gviscio/ on his profile you will find his web sight in the top corner. KEEP THE FAITH my brother.

Here in lies the problem.  So what I have found and I will investigate further is all of the help websites are based on the premise of the appeal a denial.  Some even work on writing letters to the ins. company to substantiate necessity.  My insurance company United Health Care is trying to tell me that not only should I have not gotten the approval,  I was never supposed to be allowed to appeal in the first place.  They have stated that medical necessitiy is a mute point as the entire procedure is excluded.   I will look again but to be honest I am increasingly drained and saddened.  Here is another fine point.  United Health Care will not pay for any dietary help for any form of weight loss what so ever under my plan.  However now that I am clinically diebetic I can get all the dieticians I want becuase I have diebetes so I need to lose weight, but they won't cover me to see a dietician to lose weight so I don't get diebetes.

Davo -

I, too had UHC at one point and was told the exact same thing.  If you still have your copy of the benefits and exclusions, get to reading the section entitled "Exclusions and Limitations".  There is usually a statement to the effect of "Surgical and non-surgical treatments of obesity even if deemed medically necessary......." blah blah blah.  If that is listed in the exclusions, then you have a true written exclusion and unfortunately that is pretty much a dead end.  I am still, however, baffled that you did get an approval from them and then had it yanked.

Also, I commend you on being as composed and professional in your postings about UHC as you have been.  As a friendly reminder, don't post anything here that you would not want drug in to a courtroom.  Those insurance companies have guard dogs who lurk on these boards to read what is being said about them.  Anything you post can become evidence for or against your cause thanks to the whole "public domain" nature of the board.

I feel your frustrations.  Don't give up and remember to hold your head high no matter what.  We're still pulling for you!

Hey Davo, If the procedure is excluded from your policy I believe that was the option of the company that chose the policy, i.e., your employer.  You should try taking it up with your HR department and see why they excluded this procedure.  Maybe you can persuade them too add it for next year?

Davo -

I had UHC 1 1/2 years ago when I was first approved and was approved in 3 days. I know at the time UHC just settled a class action suit for many denials they did the year before. Maybe they changed their SOP'S. I know have Aetna.

I would also review the policy to see if it is specifically excluded. Also this time of year is when most employers have the benefit changes (where employes can change coverage and companies). Might be worth looking into.

Good luck and keep ur head up!!

Sean

When I went to my Dr. and we discussed over several visits the surgery neither of us had ever dreamed or heard of an excluded medically necessary procedure.  Go figure.  I sent the claim in and was told that it was denied however on numerous occassions was told I could appeal.  I did and then the lost paperwork excuses started.  I submitted paperwork on three seperate occasions over an 8 month period.  Finally I called and demanded a response and I was assured I would have a written response within 10 days.  Seven days later my approval after appeal showed up.  The rest is history.   It is interesting to note that when I contacted my HR department about 1000 times all the blame of the exclusion was placed upon the insurance company not my companies choosing of our benefit plan.  Of course the insurance company sayds oh no its their fault not ours.   If my company abides by my request I should recieve a final word today.  The insurance company has now had an addtional 12 days to reveiw how things go screwed up.  After contacting 3 attourneys all have said it is a gamble to take them to court, I could win or it could go on for a long time and I would be out money we don't have as this is not a wrongful injury case it is cash up front. Oh I also talked for an hour with our company president and was told in no uncertain terms how great our coverage is and  I qoute "Its not like we are going to change plans becuase you need surgery,  most companies don't cover this"  and from my HR director "it really is the insurance comapny that has limited us with this plan unfortunately and this is the best coverage for us."

Davo, I've also been following your posts and I really feel for you and the frustration you are feeling with the runaround you are getting.  When I first considered WLS about a year and a half ago, I did a lot of research and was really put off by the number of people that were having such a hard time getting approvals from their insurers.  One of my personal faults, aside from overeating, is that I have an extremely low tolerance for bureaucracy and red-tape and am often inclined to just give up rather than methodically pursue the results I want/need.  So, I bit the proverbial bullet and did the WLS as a self pay.  I was surprised that it was reasonably affordable (for me as a single guy anyway).  I had the VSG and my costs totaled about 19k to 20k which is tax deductable which helped a bit. Doing it as a self pay is risky since any complications also end up being self pay but I was fortunate that I had no complications and was in and out of the hospital in one day. I know that self paying costs like this isn't an option for a lot of people but in my case, it was ultimately very much worth it.  As you deal with your insurer, just know that there are other options available. JP

Davo, I wish you the best and hope you get some resolution. Some other posters mentioned this as well. If there is an exclusion, I would talk to your company for exceptions. UHC approved me in no time and they are known to be very good about WLS. Some companies try to cut corners and expenses by negotiating certain exlusions with the insurance companies to make the premiums less. WLS is a common exclusion that the employers do, not UHC.  Its sounds to me like they sent you the approval before they realized (or did the proper research on their part) that your particular employer exluded it from their policy.