Insurance denied me. Long

Hey I just wanted to let you know that United Health Care denied me. They told Tarra at OHSU that they sent out a letter something about my BMI and my 3 year history. So I thought I'm going to call them myself and find out. The first Customer Service person I talked to said something about treatment not consistent with info submitted. I don't know what that really means. So she sent me to the Care team that makes the decisions. They told me I was not denied because of medical reasons but because my plan doesn't cover it! I said WHAT??? that was all the info they would give me and told me to wait for my letter. It was sent from Irvine CA on the 30th and is still not here. So I got off the phone and called my DH (he carries the insurance) and told me and he went straight over the the HR manager and said what is going on. We paid for this outrageous plan because it has this surgery. She said I know company covers it and nothing changed from last year. So he has a call in this the big wig and so I'm lost. I don't have a clue what is going on and not sure what is taking so long to get my letter. I am so disappointed and just over all tired. I can't even believe how much this has taken away from my life. I sit and wait to hear something after waiting for appt's and tests and wait for the January to submit now this..Arg I feel so defeated I thought about giving up but to tell you the truth that is what they hope I do. So HA not in this life. I will fight this and WIN! ok anyone with experience HELP ME! LOL I'll keep you posted as to what the letter says and the next steps if anyone cares lol. Rebecca ~ Beaverton

Rebecca, My paper work was in their hands less than 24 hours and they denied me, saying it wasn't covered. I had already talked to several people at the insurance and had gotten different answers. It made me mad and more determined to make them cover it. I called again and gave them the page numbers in the contract book that said it was covered. THEN they started to give me information on what was required to get it covered. Medical necessity etc. psy eval, nutritional eval. endocrinologist eval., letter from my primary care physician. Once I got that in (it took about a month) then approval was quick. They needed a thorn in their side to get it done. You are right in thinking they hope you give up. Once I got the approval, the insurance people were very helpful to me. KEEP AFTER THEM. If your husbands employer says it should be covered, then it probably is. Don't give up. I know it is depressing but remember it is your life so fight for it, don't give up. My prayers are with you. Julia

Hi Rebecca: I had the same problem and so did my co-worker. We both work for a County and did very careful research to make sure the surgery was covered. We got yes from everyone and so did the Legacy Obesity Clinic. The lady at the clinic also had the name the person and their telephone number who verified that the surgery and procedures were covered. Then when we get into it we started getting denial letters for the bills. This went on and we would fight each one of them and eventually someone would actually look at our plan and say oh yes, guess that is covered and would pay the bill. The last one of these I received was a day before my surgery. Our contact for our insurance went absolutely balistic and sent a very hot email to the contractor who handles the claims. Basically told them to get their act together. The funny thing was that with one of the claim denials came a letter authorizing the stay in the hospital. Anyhow we both have had a very successful surgery, one in December and one in January. What we learned was hang in there. Now let me hope I am not jumping the gun as I have not seen anything from the hospital or surgeon. They tell us now that our files are flagged with the information that yes this is covered. Just hang in there, you will prevail. Jeanne

I like your attitude Rebecca! You hang in there and fight them! I'll bet if you send confirmation of coverage to OHSU, they will help you fight too. I'm hoping I don't end up having any troubles with insurance. My BMI waffles between 39 and 41 on any given day, and I need to have a BMI of 40 and my co-morbidities for coverage. I'd hate to be denied for two pounds! I'm sure the insurance would be strict enough to do that. They always like to get out of paying whenever they can. Let us know how it goes. We're all sending coverage vibes to you! Linda

Many of us have had to take an indirect and sometimes stressful route to getting approval. Persevere and don't let the insurance industry get away with not providing services that they are contracted to provide. By the time I got approval I think the two women in the Chicago office where my insurance was based were rooting for me. Always take names and keep good records of your phone conversations. I could be told two completely different things by two representatives in one day. It can make you feel desperate! Keep on them, I think they do count on a portion of people just giving up. Patty

I waited for an answer for 3 weeks then I was denied. I just crashed when I found out. Mine was because my doc did not send the 5 year weight history as medical records. She sent it in her letter. I just cried and binged and decided everything I have done so far was for nothing. This whole week has gone to hell because of it. I personally know not to give up because right now I know why they denied me but just hearing that made me crash! My weeks starts over tomorrow and I go back to my liquid diet and weigh in and try to explain why I gained weight this week and hope they let me stay in the program. I wish you lots of luck! *hugs*

Keep fighting Rebecca! GO FIGHT WIN!! **cheerleading for you** GO FIGHT WIN! Rebecca M. 269/161/155

Rebecca: Hang in there, Girl! Fight the Fight and don't let those insurance people ( ) dictate how your life will/won't change because of this procedure. Thinking of you!! Jana 300/268/below 200 Lap RNY 1-3-07

Hi Rebecca, I just had my RNY surgery (originally denied by my insurance company) and it was covered!! At first I had gone through the whole gammit......long process as we all know. My claims was submitted to insurance and was denied....I think the insurance guy read the first line and said "DENIED" then left for 2 weeks on vacation...ARG....;-S My surgeon had what is called a peer-to-peer (telephone conversation with the insurance so called doctor immediately upon his return) My claim was then approved. When I saw my doctor later, he told me that the insurance company claimed they didn't get all the information needed (a stall tactic because we all know they did) and the denial was overturned. First denial said BMI not high enough for 5 years. The approval was based on BMI over 35 for 5 consecutive years and high blood pressure that does not respond to medicaton and WAS dangerously high. Insurance companies are so egar to deny that I think they simply don't look at all the facts and as you said, they are hoping you will drop it. Good for you for hanging in there, it's worth it, although I know it's very, very hard to do. Very many of us have traveled the road you are on right now and prevailed. NEVER GIVE UP!! Darla

Rebbeca, don't feel bad, you have alot of people pulling for you . What a great group on this foram. Like you said you don't know the whole story yet, and you might be surprized the next time you pick up your mail .If the boss is in there on your side ,it may make all the differance . Keep smiling ,and push forward. Jo Ann S.