Question:
No resposne the first time...I'll try again :-) I was denied...

by my insurance, Trigon Healthkeepers(VA). This was not a denial for the surgery but for the initial referral consultation with the surgeon. My insurance is paid for 100% by my agency. No out of pocket expense for me to participate in the health plan and 3 years ago a coworker had a RNY under the plan. As an aside, my director was considering changing insurers this year but due to cost chose to remain with our current company. She told me that when she signed the renewal she trusted that it was the same policy as always and hadn't noticed that they removed the GASTRIC BYPASS RIDER the supposedly allowed the other coworker to have the surgery approved(this is probably how Healthkeepers got the rate down to a competitive figure). She called the benefits manager who said the rider couldn't be added until our next renewal in Jan. '02. When I talked to the insurance company they said I wasn't approved because my agency DID NOT PURCHASE THE RIDER *NOT necessarily* because of medically necessity. I'm wondering, since I know they will approve the surgery, if there is any way to bypass this rider thing and get Healthkeepers to pay?    — [Anonymous] (posted on May 22, 2001)

May 22, 2001
I hate so say it but I really don't think you'll be able to do anything about it. I guess you could try to appeal to your agent along with an appeal letter from your employer if they are willing to help you out. Have your employer explain the whole scenario how they assumed they were choosing the same benefit package and they were not forwarned that any changes were made to the contract. But I don't know that you have a strong enough case for them to reconsider. I'd give it a try though. Can't hurt.
   — Karla K.

May 22, 2001
I have to agree with the other writers. Unfortunately this is "not a covered benefit". That is what the insurance company will write you, and there is really no appeal except through your employer. I hate to say this, but I am sure they are aware of the exclusion, like you said it probably kept there rates down. Don't forget that that co worker's sugery cost about 20K. That's a lot for a company to have to cover, especially if they are small. I would however call provider relations at the insurance company, and ask them if a company can add additional benefits at any time they want too. Then it will be up to your employer. Janet
   — Janet W.

May 22, 2001
You need to speak with your employer. They have the power to "lift" this exclusion. I spoke with a triage nurse who says this can be deleted from a policy by the policy buyer. However, if your company is large and this would increase your company's plans excessively, they most likely were aware from the beginning what was going on. But if you are a small company, I would have a one on one talk to see what they can do. Have a conference call between the company, insurance agent and yourself to see what can be done.
   — [Anonymous]