Question:
HAS ANYONE HEARD OF AN EMPLOYER OVERRIDE

I WAS TOLD THAT UHC LETS YOUR COMPANY DO A ONE TIME EXCEPTION BY LETTING THEM DO WHAT IS CALLED AN EMPLOYER OVERRIDE TO REVERSE THE DECISON THAT THE INSURANCE HAS MADE IN REFUSING TO PAY DUE TO AN EXCLUSION IN OUR POLICY. HAS ANYONE EVER HEARD OF THIS OR USED IT TO HELP THEM.    — Nickie G. (posted on July 11, 2003)

July 10, 2003
Yes, I've heard of it. I was told by my former insurance company that they would approve my WLS only if my employer agreed to an exception and was told to contact my HR person. I did and hit a huge brick wall. What you end up with is having to convince a single person to present your case for review with your employer. If that person has any prejudices against WLS, then you have to go higher, present a grievance, etc. I didn't want to go through that and I knew Maryland was passing laws which change all that for me, so I waited. But don't let me discourage you. Go to your HR Manager and ask if they would consider an exception if you can provide them with documentation from your PCP and surgeon saying the surgery is medically necessary. You may be luckier than I was.
   — antiques55

July 11, 2003
It depends on who is fiduciary for your plan. If your company is fiduciary (or financially responsible) then they have the capability of overriding the plan's decision. If the health plan is fiduciary, then your company cannot override their decision. I know this because I work in the health care industry.
   — BarbC

July 11, 2003
Hi... My husband's company did an override on the denial by BCBS-Carefirst in MD due to an exclusion even with Maryland having a wls law. They were an Erissa company who self-administered their plan. With that they could change the final decision and they did after two denials, an appeal denial and a heartfelt letter from me using buzzwords like company loyalty, quality of life, untimely death if I didn't have this, etc. It worked and within 24 hrs of sending them the letter it was reversed. I had surgery 4/2/02 and am down 114# and feel super. So fight! My best to you.
   — AJC750

July 11, 2003
I would check my rights if I were you. This year a new law was passed about health confidentiality and your employer no longer has the right to your medical information. When I went out for my surgery I asked my doctor to tell my employer as little as possible about the nature of my surgery and he wrote the letter indicating that I needed major surgery and how long I would be out. Even if the company owns the insurance company, I think you have rights under this new law. If I am right you may need to get a lawyer.
   — Ron T.

July 12, 2003
Hi there. I actually was finally approved by going through my benefits administrator at work. It was well worth it. It took 2 weeks to get an answer but that answer was yes. I am scheduled for August 4th. I hope you find your way. Do whatever it takes and try anything to get you on the process. Most companies will approve. Try doing a cost benfit analysis and sending it to them.
   — trijnity

July 12, 2003
If you have to present a letter of medical necessity, I suggest personalizing the generic one on this site. First click on "Your Journey," then "Insurance Troubles," next "Getting Authorization," and finally "Letter of Meidcal Necessity." It's a good letter listing comorbids with statistics and other information. This may help with convincing your company's insurance personnel. Hope this helps you. Good luck in your pursuit of WLS.
   — Beth B.

July 12, 2003
To Ron, below: I think you're misunderstanding the issue here. Her employer has an exclusion in their insurance policy that prohibits WLS. No one has breached her privacy and given personal medical information to her employer, but the only way she can get the decision overturned is if she contacts her employer and gets them to agree to override the exclusion in her case. So, it's a choice between voluntarily apprising her employer of her medical information or NO surgery. I've heard of people having some success with this. HR people aren't heartless. It's one thing to sign up for an exclusion to the policy before the fact and quite another to turn down an individual who's been loyal to the company, face to face. On the other hand, I'm not sure how they could make it a "one time" over-ride. It seems to me that once they've opened that door, others at the company who know you got approval have a case if they get denied. Anyway, good luck, it's certainly worth a try, right? I understand people are reluctant to talk to their employers about this, but I've heard of employees who have and employers who have changed the exclusion in their policy when they did!
   — sandsonik