PPO Insurance Coverage

[PrincesaJenE 0]

I had the lapband procedure done and it was completely covered by my PPO insurance through Aetna. My sister has expressed interest in getting the lapband. However, her company is telling her they will only contribue $5,000 and she'll be responsible for the other $7,000. She does not have this money and it will take her quite some time to save it up. I don't want another year to pass with out her feeling the same victory that I have felt. Her insurance is a PPO and its Fiser/UMR. Does anyone know about this company or how we can get them to cover more?

Edited January 30, 2010 by PrincesaJenE

[honk 780]

Coverage comes down to the contract that usually your employer has written with the insurance company. Insurance companies usually have a arbitration (not sure if thisis the right word) group that you can call to dispute a coverage rulings.

[tampa terri 0]

Though you may both have plans through the same insurance,it's true that benefits are based on the amount of coverage the employer wants to pay for. Unfortunately, if there is no coverage in the policy for bariatric surgery, even an appeal for medical necessity is not going to get it reconsidered. She should check with her employer or read her benefits book to make sure it is truly not a covered benefit. Many times an insurance will give incorrect information over the phone until you question them or can prove them wrong. Good Luck!