Question:
Self-insured/no written exclusion, ridiculous criteria!

I am preparing my appeal letters to both my insurance (third party administrator) and the benefits committee where I work. Both the insurance and the committee denied me benefits. The benefits committee thought I was asking them to extend our current benefits when I asked for their support. I want to make them understand that I want them to make the insurance revise their ridiculous criteria so that I can get benefits under our current package. Since there is no exclusion, I am entitled to these benefits as long as I can prove they are medically necessary. I feel I must be missing something here, so I want to make certain all of my bases are covered in preparing the appeal materials. First, I am going to write a letter referenceing the ADA guidelines, EEOC guidelines, NIH guidelines, all of which show I am considered disabled and that I meet the NIH guidlines for treatment so I can probably prove discrimination under the EEOC rules. They offer benefits for alcohol and drug treatment, so they must offer the same to me, a disabled person, right? I want to make sure I am right about that before I start making claims that could come off as threats to my company. I have worked here 7 years, and I do not want to make big waves, BUT I do want this surgery. Second, I am going to ask my ortho to write me a letter, as well as my chiropractor. I don't have high bp, diabetes, cardiac problems or anything "life-threatening" (other than extreme morbid obesity.) But, I do have GERD, joint pain, back pain, shortness of breath on exertion and of course a BMI of 53. So, do you think I should concentrate on getting my company to make the insurance revise their criteria to a more reasonable standard, (see my profile to read the criteria I am referring to)? Or, should I go after them with the ADA information regarding discrimination? I don't know if I can afford a lawyer, so I don't want to spout off in these letters that I am going to secure legal representation to press the matter. Also, I don't know if a lawyer would even help since my company is self-insured. Any advice would be really helpful.    — Diana M. (posted on July 9, 2001)

July 9, 2001
Hello, let me know if you're successful....I'm into my 3rd appeal now. You may also want to mention incontinence (sp?), any rash from stomach apron, depression, diabetes run in the family? ..... anything that applies. Best of luck to you, please keep me posted~
   — Gail R.

July 9, 2001
Unfortunately I don't suffer from incontinence or have rash problems from the stomach apron. Other than back pain and past gynecological problems, that were life-threatening but now aren't, I only have a high BMI and a family history of High bp, diabetes, asthma and cardiac problems. Who knew someone could be so obese and still be considered too healthy. I would have to be at death's door with these people, and that is why I want that criteria revised. I am so frustrated with this whole process and know almost nothing about the proper procedures to follow.
   — Diana M.

March 11, 2004
My company is self insured and the lawyer handling my case is: Gary J. Viscio, Esq. Resnikoff & Viscio, PC 145 Willis Avenue Mineola, New York 11501 (516) 742-5300 Fax (516) 742-8130 [email protected]
   — doodlebug