Question:
Do I have a case for appeal if they lied and misrepresented?

Hi, I am in South Florida and have a question: Well, I had Cigna before and it was obvious that they werern't going to cover WLS. I had the option to switch to United. Before I did so, I talked to United to be sure that there were no exclusions for WLS. I was told that there were none for WLS. So I was quite excited about this. Switched to United. When I got my book with the lists of exclusions, I double checked. It said it did not cover weight loss programs, but nothing about weight loss surgery. I got the ball rolling, was waiting to hear back with an acceptance. Denied. They tell me that the wording is different on the books than their computers. Their computers say neither WLS nor weight loss programs are covered. I'm furious of course. I'm considering contacting a lawyer. Has anyone heard of this happening before? Could I have a case for appeal? Please feel free to contact me personally or on here. Thanks for any help, Kate Underwood    — Kate U. (posted on March 27, 2004)

March 26, 2004
That is unreal!! I say YES! you have a case, who gives a rats what their computer says. If its in the book then no way they can back track. I would first ask to talk to the highest supervisor, threaten legal action to see what they say and then I would talk to a lawyer if they don't budge. I did medical review at a well known ins/review company and the policy was, if a letter went out saying it was covered and it wasn't, we would have to cover it due to our error. This is similar because its in writing. BEST OF LUCK!
   — ZZ S.

March 27, 2004
HELLO KATE! MY SURGERY DATE IS MAY 17,04 AND MY INSURANCE IS UNITED EPO OF TN. IN MY POLICY BOOK IT STATES THAT NO WEIGHT LOSS PROGRAM IS COVERED THROUGH THEIR POLICY, HOWEVER, WLS IS COVERED 100% AFTER A $250 CO/PAY. I KNEW THAT UNITED IS KNOWN FOR THEIR WLS EXCLUSION, BUT IT VARIES FROM COMPANY TO COMPANY. SO, AS SOON AS I KNEW I WAS GETTING THIS INS. I CALLED TO VERIFY THAT MY COMPANY DID NOT HAVE THE EXCLUSION. THEY TOLD ME NO AND IT HAS STAYED THAT WAY RIGHT UP UNTIL APPROVAL. YOU MUST BE SPEAKING WITH YOUR CARE COORDINATION DPT. ANYONE ELSE WILL GIVE YOU WRONG ANSWERS. MY CASE WAS HANDLED STRICKLY W/ THEM. TO THIS DAY IF I CALL ANY OTHER DEPT ABOUT MY APPROVAL NO ONE KNOWS WHAT I AM TALKING ABOUT. KEEP ON KEEPING ON! THIS IS A GREAT INS.
   — Brandi C.

March 27, 2004
looks like they have have hired some people that use to work with cigna...LOL..sorry i know i am of no help.
   — jellyin

March 27, 2004
Sorry for your problems. I'm guessing that someplace in that book there is a disclaimer of some sort to protect the insurance company. Good luck
   — barbara A.

March 27, 2004
If you got UHC in 2003, and at that time WLS was covered, and their policy changed in 2004, you might not have a case. It's worth discussing with an attorney. I have UHC and WLS is listed in the exclusion section of my policy and it reads: "except with a diagnosis of morbid obesity." I would also check with the human resources department if the insurance is through your work or your spouses work. Generally, the HR department will have the most recent version of the insurance contract and can tell you specifically what is and what is not covered. You might also call United back and ask to speak to a care coordinator who knows more than the customer service rep that answers the phone. I'm sorry to hear of your difficulty, but wish you luck!
   — Shayna T.

March 28, 2004
Don't call a lawyer just yet. Contact the department of Insurance in florida. Explain to them that you have been denied a surgery that is not excluded in the policy they sent you, and that you signed up for. UHC has to respond to the DOI regarding your claim or they are assesed penalties. UHC takes DOI complaints very seriously and will do everything they ask. I worked for UHC handling DOI complaints...trust me. Now, if there was a mis-communication regarding policy years, you may be SOL. But seeing as they sent you a new policy book, I do not see how there could be. Anyhow, DOI is your friend. :)
   — RebeccaP