Change in insurance requirements. :(

irishprincess966 · March 25, 2011

So I have Federal BCBS. Last June started seeing a nutritionist in order to started on the process of getting WLS. In August I started seeing my metabolic dr who put me on weightless meds, a new exercise plan, etc. I did everything my doctors and insurance company told me to do to meet the surgery requirements. I had to do the standard "dr supervised diet and weight loss" for 6 months. I have lost almost nothing. Come February I made my appointment with the surgeon. I called my insurance company to make sure he was still covered (they don’t always update the website) and found out that all of the requirements had changed as of January 1st. Now it is 1 year of Dr Supervised diet and weight loss, 3 consecutive months with a Dietician, 6 months of quitting smoking prior to surgery. I spoke with the nurse who reviews the cases and she said they have some flexibility and made me feel more confident that they would approve my April 18th surgery date. Well that was just a bunch of hooey because now my claim is in and they are saying that they do not have the ability to waiver at all from the requirements and the soonest they can approve it for is August. Here is the problem, I am in training for work in from May to August and then start Grad School at night starting the end of August, 4 days after my training is over. I am going straight for the next 3 years so I can finish before I start losing credits. So after all of this, it looks like I won’t be able to do it at all. I feel like all of this time I was running a 5k and just found out that it is actually a 10k triathlon, and I don’t know how to ride a bike or swim. Maybe I should just resolve to be fat and unhealthy because I have tried all of the “conventional” methods of weight loss and none of them have worked. I rescheduled my life to be able to have this surgery on April 18^th and now it looks like it was for nothing. It took me so long to get to the point where I am willing to do the surgery, just to be let down and not be able to do it. I am so frustrated and angry I could start crying again. Anyone have any advice on how to fight the insurance monsters?

MRSKOUBiK · March 25, 2011

I wish I could offer advice, but I'm bad in that area.

I just wanted to say good luck!

SunnyinSD · March 25, 2011

I'm SO SORRY. I'm in a similar boat - my BCBS of IL just changed their requirements from 3 months of dieting to 6 months - and they changed it AFTER I submitted for approval and yet I was still denied. So I feel your pain. But at least I only have another 3 months of dieting. And I have work commitments in the summer also, but not for the next 3 years. I'm not sure that I have any advice for you except to try to appeal. And honestly if I were in your shoes I might think about postponing either starting grad school in the fall or seeing if you can do a leave of absence for a medical condition (a lot of programs will allow you a certain amount of flexibility in making up for missed classes because of an illness). The worst that the school and insurance can say is "no" but you have to be willing to FIGHT!

KinkySlinky · March 26, 2011

The only thing I can suggest is to send in an appeal... Something else you might try is contacting your HR department.. or whoever is in charge of selecting the medical insurance plan and try pleading your case... The thing about insurance companies is that they do not set the rules... It's the EMPLOYER... so I'd appeal your insurance, if that doesn't work, start with HR.. It's going to take a lot of time and dedication, but if you're persistent, you might have a chance? Let the benefit decision maker know that you were in the process of doing the required monitoring prior to the insurance plan being changed and you want it to be covered..

I will tell you that my insurance has a max of $10,000 per procedure.. Well, the hospital itself has a contracted rate of $17,000, that doesn't include the surgeon, the anesthesiologist, etc... But with a few days of thinking, I have been able to find a way around this... But it took some time, a lot of phone calls, and some bargaining... Good luck!!