Question:
Has anyone had problems with their EMPLOYER not ok-ing surgery?

Here's my problem. Once I decided to have the surgery, I called my insurance co. (FMH BENEFITS) and they said it was covered if proven to be a medical necc. I called HR and SHE called the ins. co. and said the same thing. So I had the necessary reports sent in and it was deemed a medical necessity. Well once HR started looking at the policy, all of a sudden it's NOT a covered benefit. I looked in the benefits book that was handed out a little over 90 days ago (got it from a new employee) and it's not in there. I asked HR to fax me the part about it being an exclusion. She faxed it and it's in there, but not in the book. HR said I could write a letter to the Benefits Committee and ask them to reconsider but she just wanted to let me know that "they don't normally change their minds on something that is excluded ~ but feel free to write. I talked to the Surgery Coord. at the surgeons office and he said that since we are a self insured com. they could determine what they would pay for. He said to write the letters and if neccessary, write the Ins. Commissioner (since the exclusion wasn't in the book) I was just wondering if anyone had any similar problems and what they did to solve them. I'm ready to say FORGET IT!!! I don't want to run the risk of losing my job by pushing the issue.... *and they can/will 'find' a way to get rid of you**!    — MICHELLE F. (posted on December 30, 2002)

December 30, 2002
If this is a self-insured firm, the Insurance commissioner can't help. Self-insurance is governed by a federal law named ERISA. The US Department of Labor handles ERISA issues in the department called the Pension and Welfare Benefit Administration. Even though this is a big department, there are federal employees there who are assigned to answer public questions, and do so fairly quickly. Look online at the Department of Labor site. It will give you some information and also the phone number at PWBA to call. I hope that someone there can help you!
   — Beth S.

December 30, 2002
Here is a web page where you can get started: http://www.dol.gov/pwba/aboutpwba/main.html. <br> If you need to get in touch with someone, try starting with: http://askpwba.dol.gov/ <br> Good luck, Beth
   — Beth S.

December 31, 2002
Write a letter with all your documentation, submit EVERYTHING! Copies of past diets if any..pictures..Co morbs. The reason I say this is that my company is self insured and i needed a Tummy Tuck. I sent letters of medical necessity, pictures and so forth and they finally approved it. I got the run around, but anything worth having is worth fighting for! Good Luck....if you have any questions let me know!
   — Donna J.

March 17, 2003
I HAVE UHC-EPO THROUGH MY JOB ALSO AND IT LOOKS LIKE THEY HAVE AN EXCLUSION AS WELL---I AM GOING THROUGH THE APPEALS PROCESS
   — A M.