Question:
Aetna's policy on small companies; Insurance - 7/06/2005

I work for a small employer (15 employees) headquartered in VA. As of July 2005, we are in the process of switching to Aetna (HMO or PPO I'm not sure of right now). UGH - I read somewhere that as of January 2005 Aetna's policy of covering WLS (for small employers) is allowable ONLY if the employer purchases the morbid obesity rider. I'm pretty sure my employer will not purchase the rider (out of 15 employees I, unfortunately, am the only obese employee). BUT - I reside in MD which has a law/bill that ins. providers must cover the surgery if deemed medically necessary. I think VA has such a law, too. I am only 5 feet tall and my BMI is 54.3. My GP referred me to Dr. Fullum in Washington, DC in May 2005. Does anyone think I stand a chance? Thanks in advance.    — T L. (posted on July 6, 2005)

July 5, 2005
You would be governed under the state where your insurance is from. In this case VA. It doesn't matter that you are a MD resident. The insurance policy was sold and is administered in VA therefore subject to VA State laws. I'm not as familiar with VA laws so you may want to get in touch with the State Insurance Commissioner for VA and find out what your rights are. Michelle "Pookie" Engelmann Founder and Co-Chair Maryland WLS Legislative Action Committee
   — Michelle E.

July 7, 2005
Hi- I also work in a small sized company- & have Aetna- I spoke with my surgeon- he has had patients approved this year for WLS. I was told by Aetna- that I needed the rider back in 2/05,only to have my office manager call their contact & be told we did not need it- but were referred to their bulletin on WLS- on their website- I think its Bulletin#150, & was updated dated April'05. I DO KNOW theyhave declined patients for not having meet the 6mos diet/doctor monitored seight study- that is outlined in the bulletin. As far as the policy rider is concerned- we renewed our policy in 9/04 with nedxt renewal 10/05. They began putting this ridercrap into effect (they told me in Oct'04. I told them if we renewed in Sept and were NOT advised to include a rider at renewal- and our first available renewal is OCT.'05- they HAD to abide by the policy terms that are in effect as they are. They had to agree with me. That was back in February - I have just cleared all my medical tests as of July 5- including the 6month diet study- so I should know within the next two weeks- regarding approval. I also have Dr.Garber, who is well known, and he told me, that when he has had declines, he would call the medical director, and get it reversed. And that he just he advised me- at my 2nd consult 6/05 -when I asked about Aetna approvals. Hope this helps you- Donna
   — nybabe

July 7, 2005
UPDATE:<br> Michelle and Donna: Thanks for both of your responses. <p> I contacted Aetna and the VA insurance commission; both gave me the same, dissappointing news. <p> Here it goes:<br> True, VA law does state that providers must cover WLS if deemed medically necessary BUT here's the catch/loophole: So long as the insurance provider OFFERS the coverage, even in the form of an optional Morbid Obesity rider, the insurance provider is in compliance with state law. It's up to the employer to accept/purchase the optional rider or decline it. <p> I feel my only option at this point is to try to convince my employer to purchase the rider. <p> Congratulations to all who've successfully gone through the process and good luck to those just beginning the journey.
   — T L.