Question:
Anyone have a self-funded insurance w/exclusion and fight it?

I just want to scream!! Why is it the insurance company skate around these issues?? How can they get away with denying coverage when it can be proven as medically necessary by 2 doctors with co-morbities just because THEY chose to write it as an exclusion? Is there no consideration as to the health and welfare of the living person behind the request. I don't understand. What's worse is never being able to get a direct answer on how to fight it or if it can even be fought! Add onto that the fact that the "insurance company" is acting as nothing more than in an administrative capacity because the "insurance" is actually paid by the employer because they self-fund the insurance is even worse! Anyone out there have a written exclusion that reads (similar) "Medical or surgical treatment or regimen for reducing or controlling weight, including morbid obesity" AND know that the insurance is a self-insured or self-funded plan? I don't know where to go from here. I've gotten 3 different stories from 3 different people at the insurance company. Forget about talking directly to the HR department at the company because I was advised (and I quote)...you would have to, more or less, be dying before they would approve you. WHAT A HORRIBLE THING TO SAY TO ME!!! Doesn't the fact that my BMI is 57 or that I have sleep apnea or diabetes and other issues be a factor for a decision??? I don't want to start the procedure without first getting pre-authorization. My PCP can help me obtain most of the pre-surgical testings because he can refer me to have them instead of the bariatric surgeon but I'm so confused, upset and MAD as all heck about this. HELP. Rose    — Roezee (posted on January 7, 2006)

January 7, 2006
Rosie, I can totally relate to what you've been through. I was there, too. Only I had 5 doctors write letters of medical necessity, my PCP had told me I had less than 6 months left to live, and I had been in a wheelchair for nearly 2 years because of the damage that the weight had done (and was doing) to my back and knees. I had out of control diabetes, stroke level hypertension, severe obstructive sleep apnea, congestive heart failure, horrible gerd, stress incontinence, and was on 23 prescription medications. My doctor said to them if they didn't pay for my surgery I'd be dead. They said, "Sorry, nothing we can do about that." So - I self-paid for my surgery. I did my research - found the most experienced surgeon I could - and went to Spain to have surgery with him (Dr. Aniceto Baltasar). Surgeons in my area were doing the DS in as much as 6 to 12 hours. My DS was 80 minutes and included appendix and gallbladder removal (I had HUGE gallstones!). My starting BMI was 64. Today it's 25. Then - 3.5 years ago - I had no way of knowing how GREAT today would be. There ARE attorneys you can contact to find out if you can challenge the statements you've been given. Try checking out Gary - his web site is: http://www.obesitylawyers.com/ I've heard GREAT things about him. BUT, if time is of the essence, and you need surgery NOW not later - then seriously consider self-paying. When it comes down to it - saving your life is worth it! Let me know if I can help at all, okay? Blessings, dina
   — Dina McBride

January 7, 2006
Check your handbook on 'appeals'. Self funded they usually have your standard appeals to the insurance company; then an appeal to the company itself; then it goes to 'court' Don't just go by what the RISK manager said; check your book on the process and then get it started!
   — star .

January 7, 2006
Its a long battle, court is a several year battle, subject to appeals, the cost for a rny is 40k, plus maintence, worth the cost of delay,and appeal if you do win, you will spend half that trying. possible solutions, are you union, the union has an obligigation to secure your earned health benefits. you can self pay, It can be resonable in mexico,brazil, come to the ds forum,many xof us choose to self pay,abroad, it is often excluded, and is the preffered proceedure abroad, many choices of doctors . about 13k for the ds which is the most expensive. thats total, air hospital and surgeon.
   — walter A.

January 7, 2006
Most self funded helth insurance plan fall under the jusristriction of Federal ERISA laws. So I would do some research about those and find out how they are handled in your state. Some states have specific laws surounding self funded PPO but not HMO or the other way around or both of them or whatever. You will have to do some digging around. Good luck. Michelle "Pookie" Engelmann
   — Michelle E.

January 7, 2006
Hi Rosie, I know you want to do this yourself first but most surgeon's hire people just to do this for you, they know the in's and out's of all the different insurances. I went through Barix and they had me approved in 2 weeks with a BMI of 40 and no co-morbidites and only a weight watchers card, not a doctor supervised diet. It is worth a try to start with them, it couldn't hurt, let me know how you make out. Diane P.
   — noboat4u