New and have an insurance question

My name is Danyeal and I am just starting this entire process.  I fear that I have come to a road block.  I have Group health and saw my PCP yesterday who put a referral in for me to see a specialist.  He asked me if my insurance would cover surgery  and I said I wasn't sure yet.  I came home and called customer service and they said my husbands group health insurance with the city of lynnwood does not cover it!  He made some calls for me and hasn't gotten anywhere because noone will return calls with an answer.  I read past posts on this site and I'm confused.  Some said that if you have the plan that does not allow weightloss surgery then you pay out of pocket or find another insurance.  Then I read some other posts and if I read them correctly it said that if you have the qualifying conditions then a referral can still be submitted to insurance and possibly approved?  So if there is anyone out there that can clear things up that would be great!!!  :)

-Danyeal

I have Group Health and it covered mine.  You may want to appeal to this or call customer service at 1-888-901-4636. 

Good luck!

I've been working with customer service, too thanks!! :)  So, you can appeal if your insurance plan doesn't cover it, and I qualify healthwise for the surgery??

-Danyeal

I have been told that you have to go all the way to the insurance commissioner of Washington State to get approved for WLS if your employer has excluded WLS from their policy.  But someone else may know more about this issue than me....

Good Luck...

Helen

Helen, thanks for the info!!  I figured it would be a big process if it could be done LOL!

The type of coverage you get from Group Health depends on the employer. I am not sure about an appeal if the employer has not chosen to have that as a benefit. I have Group Health and was told my employer does not cover it. I am fortunate to have Tri-care as well. Good luck to you.

Hi, sorry to be the bearer of probably bad news for you.....

The "higher ups/management" of the company you or your spouse works for decide which insurance company they want to contract with.  Then they further decide which benefits they wish to cover and not cover.  If you called up your insurance representative and they specifically said WLS isn't covered under your "specific" policy then it is not and you can only go self pay for WLS surgery.  Do call your insurance rep and either have them send you a copy of your complete benefits, or they should also be able to give you their website for your "specific" policy so you can view for yourself.  The only other thing you can do is have your husband and other employee's talk to the companies higher ups and request that WLS benefits be added or check and see if your company offers any other insurance plans and check them out and change over if they do offer WLS during your next open season for changing plans.  Even if you do have other problems such as high blood pressure, sleep apnea, diabetes, etc., your insurance will not cover WLS unless your job/company has "paid" to include this in your benefits.

I had to go through all this crap too, and was able to change my families insurance to another insurance that did cover it - took a year, but I finally just got approved. 

Hope this helps,
ragadolly

Thank you for your response, that made total sense to me.  my husband is looking into the other plans his work offers so we can potentially change when the next open enrollment comes up. Now my doctor had already put a referral in to a specialist.  I guess I better check and make sure I won't be charged any extra money just for seeing the specialist.  Because I'd like to hear what the dr has to say before changing insurance or possibly pursuing self pay.

Thanks again for the advice!!

-Danyeal

 Personally, I would go ahead and have your PCP apply to get you into the program. Then have the program seek preapproval for the surgery. If you are denied at the point, you have something to appeal. Depending on how your policy is written you may have an easy appeal or it may be very difficult. 

The specialist visit may be covered as well, as your PCP may be sending you to them for health reasons other than "obesity" (eg diabetes assessement, sleep apnea test, heart or lung assessment, etc). Those are likely covered regardless of your policies exclusion to WLS. If in doubt, contact your insurance or ask the specialist to contact them for you.

David

GH has several different plans. A year ago, my GH plan did not cover WLS. However, when my employer switched up plans and benefits, the new GH plan that we selected DOES cover WLS.  I called and verified before my PCP/PA referred me to verify. There are only a couple of GH plans which will cover it.
It may be worthwhile to appeal, however, based on my experience in the insurance industry (previous lifetime), it will be difficult. You will need to have significant co-morbidities and be ready to fight...fight....fight.  Not sure how much good the Insurance Commissioner will do, as plans are regulated and approved at the State level for "sale" within the State. It is a dangerous precedent for a company to start.  So again, my best advise, document co-mobidities, and have your PCP refer you anyway. Plan on two appeals processes.

Best of luck to you!