Question:
Is there any recourse against an employer who lists WLS in their exclusions?
My insurance company, Humana, approves the surgery, with medical necessity---which i have (sleep apnea). However my employer has listed it on their exclusion list. Their exact verbage in the exclusions and limitations portion of the contract is,"any surgical procedure to reduce obesity" ANY feedback or advice on this matter would be very welcome. — Tina P. (posted on July 3, 2002)
July 3, 2002
have you tried talking to an attorney about that? I heard that Walter
Lindstrom is an attorney for WLS and is quite good. Good Luck!
— Jena C.
July 3, 2002
Tina, my employer also has an exclusion in the policy. What
really makes me mad is that it was just added last November
when our policy renewed. The premiums had gone up so much
that the policy was nit-picked and this happens to be one of
the things taken out. Just last week, I went to our human
resources manager and asked what needs to be done to remove
this exclusion. I work for a small company (40 employees),
but we are owned by a bigger company. She said she will call
the Blue Cross rep and ask how much the premiums would change,
and we would take it from there. I have worked for this company
18 years, and I am good friends with the H/R manager and the
general manager, so I have both of them on my side. I believe
this exclusion is discriminatory since the National Institute of
Health considers morbid obesity a disease and a disability. If
my parent company refuses my request, then I will seek help from
Walter Lindstrom. Do you feel like asking your company to
remove the exclusion is an option for you? It's probably a
good place to start. Good luck and God Bless. Ginger
— Ginger N.
July 3, 2002
Bad news, there is nothing you can do about exclusions.
— DianeN
July 3, 2002
You can always appeal to your company, but companies can exclude any
procedures they wish. If they wanted to they could refuse to cover broken
arms and legs, or refuse to cover cardiac care. They decide what product
to buy and provide to their employees. It may not be "morally"
right from our perspective, but legally it's fine. But, it never hurts to
ASK for what you want.
— BethVBG
July 3, 2002
Check with your doctor about having it worded as MORBID obesity. It is a
completely differnt medical diagonis then obesity.
— Diane Rhoads
July 4, 2002
I hate that exclusion - mine said the same thing and I hired the best
attorney in the state for fighting it - they still won. The verbage you
listed sounds very close to how mine was listed and they have something
called a Marissa law attached to it - at least that was the case for me.
With this Marissa law, it takes it into a Federal appeal and by the time I
would have paid for an attorney to fight at that level, I could have paid
for the surgery - which, I did. Good luck to you though - no two cases are
exactly the same, I believe.
— Lisa J.
July 4, 2002
I am battling the same thing. I work for a county government and was told
by my HR rep tht the HR mgr could just "sign off" on it and the
exclusion could be removed. (This was the first time we talked about it.) I
wrote a letter and attached copies of the senate bills here in GA that
state obesity is a disease and that it should be treated, medically as well
as surgically. Unfortunatly the bills don't say the insurance companies
HAVE to cover treatment for obesity or morbid obesity, they just
"suggest" they cover it....(HUH???) That makes no sense to me.
In followup calls I find out my info was passed on to the county's
insurance broker. Now they say they are "researching it" to find
out if there is "a need" for it in our company...HELLO!! I am
begging for it but I guess one person doesn't mean there is "a
need". What happened to her just "signing off on it"??
What I continue to get is alot of opinions of different people. They all
have a story about something they think they know about this surgery. I
feel my life is in the hands of a woman who hasn't walked in my shoes and
therefore doesn't care. I don't have much hope. The bottom line is if the
company doesn't want to remove the exclusion they don't have to. Oh, and I
did check with Walter Lindstrom..in the case of this type exclusion he
advised me there is very little legally that can be done because it is
legal for them to exclude what they want. Maybe your employer will be
more caring than mine! Good luck....Pam
— Pam B.
July 4, 2002
I live in Georgia also, my company also has the exclusion from their BC/BS
University System of Georgia - indemnity policy. I worked for the Medical
College of Georgia, until I had to leave on disability. The Georgia Senate
2001-2001 has presented another SB339 which would have changed the wording
from "can" to "required" for this surgery. But it did
not get passed. I don't think it was turned down, it just didn't get
passed. So, I am trying to take my savings and pay for it myself. Waiting
on surgeons approval.
— Loretta D.
October 13, 2003
I too am insured through Humana. I have to say that they are incrediably
kind on the phone. However, when I found out about my exclusion today the
lady on the phone made no attempt to find some way around this. I am not
through trying though. I did talk to my husband about talking to the HR
dept at his company. That didn't go very far. I am still going to try to
find someway to work this out. If you get anywhere with this please pass
along any info that you find that could help. Thxs.
— The-Irish-Lassie
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