Getting a company who is self insured to pay

[spalm 0]

Hi,

I am new to posting here and posted in another forum but think this is where I belong posting my question. I know there had to be posts in these forums on this same topic but I cant find them

I have BCBS of Delaware. My husband works for the union and it is self insured. BSBS at first told me that WLS would be covered if it was a medical necessity. Also, that WLS would be covered even if it was an exclusion on the policy. They gave me the criteria I had to meet and told me to have my doc submit all the paperwork. I called today and spoke with a different rep from BCBS. She said that it wasnt covered. She even called my husband Employee Relations office to double check. She called me back and said no it wasnt covered. I even called Employee Relations and they told me the same thing.

:help: Has anyone else had this same situation and able to still get approval? If so, what did you to?

It just seems hopeless!!!!

It is truly amazing how a group of trustees can decide something like this. It just baffles me that someone who may a in a life or death situation and needed something like this done immediately that they can just say sorry its not a benefit. Whats this world coming to?

[nanahanna 1]

Hi Spalm. Welcome to the group. I am pretty new here too. I have BCBS through my husband's work but it only administers the plan....the company is self-insured and they have an exclusion even for a medical necessity! But, thank God I am now eligible for Medicare due to being on disability now for two years and they will pay...so I am told by the doctor's office that I am planning on using. Do a search on "appeals" or "insurance denial" and you will get some good info on how to appeal etc. Hang in there!

[piercedqt78 658]

Submit anyway. The worst that will happen is you will be denied. There is no fee to submit for approval. I was denied 3 times and I was told that the insurance company had never paid for the band. They paid for mine. 100%, I called the union and gave them a break down of my medical expenses now and what would most likely be cut after weightloss and they reconsidered. Also if you have another insurance option and they cover the band, that improves your chances. We can choose between BCBS and United Health Care, both from the same union, well UH covers the band so the Union made BCBS cover it for me too. I know of at least one other person with the same insurance coverage from the same union that has been covered since me. If I can help I will gladly give you any information that I have. Feel free to PM me, and I will give you my number. I am always glad to help. ~Mandy

[ReneBean 3]

IF a board of trustees and decide against - they can be swayed to make an exception... put the money down on paper and show them how their costs will be lower if you lose the expected 50-60% of your excess body weight.

Any conditions that will go away? Medications you won't have to take? If you are willing to just put it out there and explain why it is important for you and your family, they might allow it.

Good Luck!!