Fed Up With Insurance Company..help?!

[hm734 228]

So I called today to check on my case and ended up in tears by the time the phone call was finished. Let me start by saying that my carrier is Cofinity through my husbands Union. They have 'claims management' through a 3rd party, Alicare whose name I easily remember because everytime I say it i think 'all i care' about is MONEY. I have been working for since 2009 to either lose this weight on my own and not need surgery or get approval for surgery.

In 2009 and 2010 I was on a medically supervised diet. Once a month I went into be be weighed. They documented my Weight Watchers, exercise, curves visits, Nut visits, Phentermine use etc. My medications are clearly listed throughout my records (phentermine for WL, metoprolol 100mg 2 x a day for high blood pressure, 1000 mg metformin for type 2 diabetes (borderline) and PCOS...the works.

Please take a min to read my requirements for WLS writen exactly as they are in my benefits booklet.

11. Bariatric Surgery

Bariatric Surgery will be certified and covered by the Fund (subject to all deductibles and co-pays)

where the person seeking coverage for Bariatric Surgery submits documentation that all of the following requirements have been met:

1) the patient has a Body Mass Index of 35 or greater with co-morbidities, or a Body Mass

Index of 40 or greater without co-morbidities,

2) the patient has either

a) completed an approved weight loss management program followed by a 12-month

maintenance period,

attempted but did not complete a weight loss management program because the

patient was medically unable or because surgical intervention was recommended, or

c) did not attempt a weight loss management program because the primary care physician did not support that as a treatment option based on presenting co-morbidities,

and

3) the patient has undergone psychological assessment establishing his readiness and ability to comply with post-surgical dietary requirements.

All requests for bariatric surgery are reviewed by the Fund’s case manager for medical necessity and

appropriateness.

As of May i have met and exceeded all of these, I was feeling very confident in my approval.

Well....now the 'case manager' said that their requirements are different than they are listed by my husbands union. They said that my documented weight loss attempts were too long ago (ending Dec 28th, 2010 / 18 months ago) It should be noted that as stated above the union office required 12 months before covering ANY pre-testing directly related to the surgery, therefore this was all started after the 12 months which is why we are now 18 months out)

She then started spewing off ridiculous requirements such as weekly nutritional appointments (which they do NOT cover), at least 6 visits for psychology, H Pylori testing, exact date of diagnosis for HBP and metabolic issues, monthly BP recordings for the past 24 months..the list goes on and on...

Can they do this? I seriously want to scream.

[BigCraig 87]

Don't give up!!!, It took me 10, yes 10 long years to get it done, I went through all the insurance hoops(mine was 6 mos of nut and 2 psyc visits along with excercise class and more)

Than after I complied with everything the insurance company said this is no longer a covered procedure by your plan

I called my companies HR and CEO and they made an exception for it. Please contact your employer and beg for an exception to get it done, explain to them how it's cheaper to get you healthy rather than pay for continued heath problems.

[JenniJune 79]

Hang in there!! Fight for it! You deserve to be healthy. Find out what you need to do to start the appeal process and start that now.

[hm734 228]

I should have mentioned that my pre-cert was not denied, and she stated they will not deny it unless I state I am not willing to comply. Frankly, I DID comply and I am not willing to play games with them.

I am also not willing to beg for them to approve a procedure they state they cover.

Has anyone had a similar experience? Where you were asked to go far above and beyond the listed requirements?