NJ & the perfect idiot

I'm the idiot that was so thrilled about a state mandate in NJ that prohibits exclusions of WLS from HMO policies. Aetna told me ever so many times that WLS was covered in my policy because of this state mandate...well, they finally found a way around it. Aetna is telling me that even though I have Aetna HMO for insurance, and even though the mandate passed on June 30, 2005 prohibits exclusions of necessary surgeries, and even though I'm a NJ resident, and even though the policy is fully funded (if it's self funded, they don't have to abide by the mandate) they still don't have to cover it because there's a deal between NJ and Aetna that Aetna doesn't have to follow that law...isn't that sweet? As of January2006, my policy will be self funded(so if they play with me long enough they really won't have to pay) so it looks like I'm the opposite of unscrewed! Anybody know a good lawyer that handles these kinds of cases in NJ. I live in Gloucester County, and I'm close to Camden County. Any help would be greatly appreciated. In essence, Aetna and NJ, together found a loophole that saves Aetna lots of Money. I wonder who made lots of money on this deal? Laurel

Laurel. Don't call yourself an idiot. It's the insurance companies and CEO of those companies who are idiots. We are the innocent people who have to suffer. I live in Gloucester County also. I"m assuming you are working and have Aetna as your insurance or you are on your husband's insurance? I am so sorry that this has happened. I don't know about you, but I'm a fighter when it comes to this stuff. I don't know any lawyers who specialize in medical insurance, but I'm sure if you open the phone book, you will come across someone. Try to find a female lawyer. I rhink they are more sensitive to our needs. I would call Aetna everyday and start asking for supervisors and managers and keep it up until you find out exactly what all this means. What kind of "Deal" are they talking about. Write to the governor, write to your congressman, write to the state senator, write to the insurance company big wigs sittin' on the hill. This country is being run by Pharmaceutical companies and Insurance companies, and you're right, someone is getting their pocket filled with this "deal". I will ask around. I do know two female lawyers; one is Personal Injury and the other is Labor and Employment lawyer. I will ask them if they know anyone you can contact about this, or if they can take the case themselves and look into it. You know as soon as the word "LAWYER" starts getting thrown around, things change quick. Good Luck. I will keep in touch. Kathy

Hello Kathleen! Have you always lived in Westville? I was born and raised and lived there for 23 years, until i moved farther south jersey to be with my sweety. I use to live on Delsea drive, a few mins from Schileen's Pub.

the key is HMO, IS A CONCEPT that separates the funding from the service, it is not a pay per item kind of thing link a pos or ppo plan, so a self funded excuse doesnt fit the design of a hmo, i would take it up with the commissioner listed on the bulitin for starters.

Actually the NJ State mandate DOES exclude self funded hmo plans as well as all POS. Irene

I don't know what they told you on the phone, but I mentioned somewhere on the NJ board in reference to the NJ mandate - the mandate does NOT apply to insurance companies that have national hmo coverage - in other words, they offer hmo coverage in all 50 states. I do NOT know if Aetna falls into that category, but this may be the one condition that could account for your being told that they don't have to cover wls. I wish I had something more positive to say that could help you. Perhaps if your policy is self funded you have a chance of appealing through your (or DH's) Human Resources Dept. Irene

Laurel, Sorry about Aetna. Chin up and give them a fight. I have read that two of the lawyers that advertise here are good. Cigna is also not too wls friendly also. The one lawyer is Liscio (i think) out of nyc and another out of cali. They have had the wls themselves and are good I have read on posts. Good luck. franni

Laurel, Viscio and Assoc. www.obesitylawyer.com on main messageboard. Hope this helps franni

Dear Laurel... Being in NJ and also having Aetna (mine is Patriot XV Flex)... your post scared the heck out of me. I called immediately to get verification as I have before to make sure bariatric surgery (including lap-band) was covered. I just hung up from members services 800-238-3598, spoke to William who confirmed that a pre-authorization would be needed but that bariatric surgery was covered. All I need to do he said, is get the pre-authorization and pay the $250 for the hospital stay. I asked about fills for the lap band. Duh...! He said that was not part of the necessary procedures and was not covered. I said "the fills are what is the working part of the procedure". Still, their medical director did not have information that this was necessary. Anyway this was just my experience. Please write back. I think we should all be informed. Pat

p.s. I live in Gloucester County too. Which surgery were you considering? Which Doctor? Hosp?