Can any and everyone advise State Emplyoees of Texas shady deal as of May 1 2003?

Over a year ago, I sat about putting a case together to override an exclusion in a Health Care Plan through the State of Texas. I worked night and day for months on what turned out to be a rather masterful case, left no stone unturned, and did any possible legwork, to minimize approval/disapproval time, etc. Was denied twice. Took the same case to the Texas Rehabilitation Commission, after lengthy changes that seemed to be fashioned as we went along, I was denied twice by them. This all took a considerable emotional toll in my spirit. But, light in the tunnel, our open enrollment period approached at work, and the miracle, in the form of a Bariatric surgery program was included in one of our two choices of carriers; that was the Scott and White Health plan administered through the state of Texas. I talked extensively with my benefit's coordinator, as well as Reps. of the Plan. No one advised me of any future difficulty. With intrepidation over already established Docs for my children and myself, in another Health Plan, I did change over to Scott & White. I saw my PCP immediately, got a referral into the program and began in October 2003. The clinic is located over an hour's drive in another city (Temple, Texas), and I began the trips there, had the lab draws, attended the seminars, and began the mandatory 6 months of work with their Endocrinology Department. The latter requires monthly visits, and assessment. I was mid way throught that part, due to finish in August 2003, afterwhich a surgery date would be set. Then, the State budget crunch set in, with all agencies being required to make up horrible shortfalls. Never before had changes in Insurance Coverage happened at times other that open enrollment (new fiscal year starts Sept 1 every year), but State Employees in the Bariatric Surgery Program received horrible news: As of May 1, 2003, the State of Texas was dropping the part of the package that included the Bariatric Surgery Program! I thought I'd have some recourse to request/demand being able to continue, since I was mid-treatment, and enrolled prior to May 1 3003. I called the Employees Retirement System of Texas, who sets Texas guidelines for Health Care Plan, and was told an even more shocking story. According to that Representive, Scott and White should "never" have been misleading people as they had, Bariatric surgery was never a covered benefit!! I asked why neither I, nor any other state employee in the program had ever been notified. I told him of my 7 months of treatment, the labs, the trips to Temple, my time taken off work, the wear an tear on my car. Who'd been picking up the tab for my visits, AND WHO'D BEEN PAYING FOR THE SURGERIES ALREADY DONE, IF NOT THE STATE OF TEXAS???? He said "only a handful" of surgeries had been done, and said out of one side of his mouth that Scott & White might have been submitting claims, but they "hadn't been being paid;" then out of the other side of his mouth came, "Scott & White will have to reimburse the State for any monies paid out to this Program." My heart is broken, I've gone along with so much hope until now, I've acted in total good faith, now this??? Please, someone, somewhere tell me whether I have any recourse in this. Surely there is a way to, at least, honor the people in the Bariatric Surgery Program prior to May 1 2003, when the state absolutely sewed up any possibility for the surgery through this Insurance Plan. Can't overstate my devastation - Would appreciate with my very life, any help and advice. There are some poor souls who were days away from scheduled surgeries, who are even sadder than I. Please, is there any help for us? Thanks so much, Pam Cerda

We greatly appreciate your interest in helping us build our Q&A database. To discourage vandals from posting garbage, however, we require people to register before posting.

You must be logged in to post an answer. Click here to log in.