State Mandate, No Exclusions?

I know this board is not for insurance info, BUT, something very strange happened today...About a month ago I called AETNA and they told me WLS was excluded from my policy and that the employer would have had to purchase a rider(sp) to the policy to cover WLS. I called 2 times after that and was told the same thing. I even spoke with the Employee Benefits Dept at work and was told the same thing. WELL, while on AETNA's web site today I read the exclusions to the policy and it said "Surgical Operations for Obesity, Except When Specifically Approved by HMO are excluded". OK, so I call AETNA to find out exactly what this means, and I'm told "you can only be approved if there is not an exclusion in your policy" Well that didn't make sense, since I was looking at my BENEFITS. So, when the woman saw that I wasn't going to just *****foot away, she got very helpful, and said.."Are you from New York or New Jersey?" When I told her New Jersey, she said OH, well in that case , NJ has a state mandate, against prohibitting WLS. So yes, you are covered, you'll just have to meet certain criteria".. SO, MY TWO QUESTIONS TO NJ FOLKS, 1) Does this sound like anything you've heard before? 2) Do you think insurance companies purposely give erroneous information to save a buck? I'd love to hear some input. Laurel

Hi Laurel, I had the same thing happen to me while trying to work with Aetna/United Healthcare. They said that my husband's employer must have written in the exclusion and because of that, they would not cover my surgery, even though I had a letter of medical necessity and a whole bunch of co-morbidity factors. Makes a lot of sense, doesn't it!?!? So sorry you had such problems. It's almost as if the insurance companies would rather pay for all of our testing, meds for high cholesterol, high blood pressure, diabetes, orthopedists, chiropractors, etc. I have to admit though, that once my husband's company switched over to Oxford (Liberty Plan - PPO) it has been wonderful. Took them a week to approve me for my LGBypass and had the surgery just 2 months ago. I hope you will find a way to have your dream come true!!! All my best, Jen Davis

hi everyone -- i also have aetna --my husband and i met with the surgeon on 9/21/05 and he's the one who told me about the 3 month diet/exercise instead of the 6 month diet that aetna requires -- but it is so nice to know that you can not be denied in NJ -- guess those idiots in Trenton did SOMEthing right with insurance in NJ haha my husband has BC/BS Horizon HMO and we have no idea what that is like -- the only requirement that we know of for sure is the Psych Eval --

Hi Laurel, In December of 2004 I called Aetna about WLS. I was told that as of 1/05 they would no longer cover this surgery. So I began a diet with my family doctor and lost 70 pounds. I still have much more to lose but, now that you have written your post I wonder if I am now eligible for WLS through Aetna? Have you found out any more information? Have you decided on a surgeon? Any info would be greatly appreciated! love, linda