Question:
Speaking to my employeer
I just spoke to my insurance company to find out where to send the letter my doctor is asking me to send along with his information for my approval. My insurance company has informed me that my company has excluded this from our policy. Has any one else come across this, and if so have you been able to get approved? I am so upset right now if anyone can give me input i would be greatly appreciated — Diane Rhoads (posted on January 7, 2002)
January 7, 2002
You should do a search on this website to see how many people have been
approved by BCBS, I'm pretty sure there are quite a few people. Then call
your insurance company and ask them about it again tell them that you were
on this site and that they have approved it for many people. Sometimes not
everyone is as informed on the policy as they should be. Also be sure to
ask them exactly what they've excluded there are very many different
surgeries. If they still tell you the same thing, tell them that you still
want the address for medical review that way at least your doctor can mail
your info, and if you are denied by medical review then you will believe
them. Even if you know you won't be approved at least you sent it there.
Sometimes you have to be tough with insurance companies and in this case
you should show them you know your stuff. The only thing you can do if all
else fails is get a new insurance company. Don't worry, it shouldn't take
long to get new insurance, but make sure you find out which insurance
companies cover it before you make the switch. Whatever you do, Please
don't give up. There is always hope.
— [Anonymous]
January 7, 2002
Sometimes the insurance companies are mistaken your best bet is to ask your
human resource person for a copy of the actual policy book. I have Anthem
BCBS and my policy excludes treatment for obesity except for surgery. The
surgery can only be approved with documentation of 18 months of supervised
weight loss and being medically necessary. It took an appeal to get
approved and at first
they denied the appeal stating there was no proof of my condition being
life threatening. I called and inquired why they changed the criteria and
told them my doctor advised me to report this denial to the attorney
generals office within hours they called and approved it and they said they
had looked at the wrong policy when they reviewed the appeal. So don't take
their word for it check the actual policy. Good Luck.
— Candace F.
January 7, 2002
As you live in Timonium, I'm assuming you have Maryland insurance? If so,
you may be ok so hang in there. Maryland passed a law Oct. 1st 2001
stating that all insurances in Maryland must cover weight loss surgery. It
is HB665. If you look in the AMOS Library for articles and go backwards
you'll find info on this. I got denied for a strange reason in November so
I sent in an appeal which included info on this bill; copies from the AMOS
site (Insurers) of who they have insured for this surgery (do a cut and
paste)a letter of request by me for appeal which included family history,
medical history, future history for me if I do not have this and if I do,
copies of the NIH standards for WLS which includes BMI, comorbidity, etc.
and the physician did the rest and included a lot of info. I'm still
waiting but I am very hopeful. Hope this helps! Hang in there and fight.
Andrea
— AJC750
January 7, 2002
It probably won't help to tell your insurance that BC/BS has approved many
others. There are many different organizations with the name BC/BS and
they can all be different from one to another. They can also change their
basic policy if your employer requests it. So, it only matters what your
policy with them says. One poster said she has BC/BS and needed 18 months
of weight loss efforts and a proof of medical necessity. I have BC/BS and
have to have 3 years of physician-supervised weight loss efforts, have to
have been MO for at least 5 years and third, have co-morbidities, although
it doesn't say how many. Definitely go to your human resources department
and ask for a copy of the policy itself. I was told by my insurance over
the phone that they did not cover the surgery, but they do.
— garw
January 7, 2002
If your insurance is a "self insured plan" which it sounds like
it is, you have to appeal to your employer not BCBS. They most likely are
only a third party administrator. Meaning they are hired by your company to
pay claims etc for the Employers plan. So technically it is not a BCBS plan
but your companies own plan that hey have decided on. I would advise you to
speak directly with human resources of your company and ask if they are a
self insured plan and then go about asking about appeal processes with
them.
Best of luck to you!
— Joelle B.
January 7, 2002
My company is also self insured and I had Keystone Health Plan Central, a
bc/bs HMO in Pennsylvania. I also got the same response that you did, that
my company didn't cover this surgery. They have a three step appeal
process and then you could go back to the company on a 4th appeal. My Hmo
basically said, we don't cover it, it has nothing to do with medical
necessity and we will not cover it. What i found out from my research and
from talking to the top benefits guy at my company is that they are
basically ignorant of this exclusion, because other health plans they offer
do cover it. I have done a lot of educating of our HR department as a
result. I was on the third appeal when open enrollment came up and I
changed to another plan that did cover the surgery based on medical
necessity. It went into effect January of 2001 and I had my referral on
January 4. That led to my surgery on April 27. My suggestion is to really
communicate with the appropriate person in your HR department. And like
another poster said, there are many BC/BS plans that do cover the surgery.
As far as your employer, I really don't think they sit down and say ok, we
don't want to cover weight loss surgery, they chose from plans presented by
the insurance company and may not be fully aware of what it excludes or the
significance of the exclusion. Good Luck with your approval process.
Cheryl
— cheryl R.
January 8, 2002
I also have a company exclusion for "weight control" From Winn
Dixie. They are the plan administrator of the policy and THEY SPECIFICALLY
EXCLUDE treatmens for "weight control"
I wrote a letter to the benifits coordinator of Winn Dixie corporation and
the guy wrote back saying sorry for your illness, but we cannot authorize
this surgery. BAH!! I am in touch with a lawyer and we are currently
looking to see what we have to do to get this exclusion over turned! DONT
GIVE UP!! KTF!! (Keep the Faith!) Bug the HELL out of your employer if you
have to. Call him every day!! TIE UP HIS FAX MACHINE with all sorts of
infor you can find on the inter net about this surgery and how it isnt
cosmetic, etc. Make the cold un feeling bastards realize that thisis YUR
LIFE they are playing with and youre not going to take it lying down!! I
will be supportive of you, and if you have any ideas for me to deal with MY
company problem, let me know, Together Im sure we could think of pleanty
of ideas to make thier lives MISERABLE!!!! Dee
— Dina L.
Click Here to Return