Denied. Service Not Covered.

[PdxMan 4,292]

My eyes read, "cash" PRIZE. LOL.

I guess cash/finance could be an option, but I think it would be a while...

Mine was $10,400, cash in Las Vegas (baby!). Stayed at the Golden Nugget ($45/night), rented a car ($150) and enjoyed a little time in the desert. It was great.

[twoolley 141]

Unfortunately not all insurance companies have come to recognize the benefits of the surgery yet. Luckily several are coming around and starting to cover it.

Also unfortunately HR departments are still full of ignorant people who don't understand the suffering that we go through. Not everyone understands what it's like to be hungry all the time, even after you just ate. Their stomach works correctly and doesn't flood their system with hormones inducing hunger. I didn't even realize until I had the sleeve that life doesn't have to be that way.

I hope you get your surgery. It's really given me my life back. I was fortunate enough have my insurance cover it but I was ready to borrow, finance, travel, mortgage or whatever it takes to get it done. You can fix a heart defect or a kidney defect no problem... but when your stomach is broken it doesn't get any attention. You just literally keep feeding the problem.

Good luck!

[JennyBeth 127]

Not to be a downer, but it sounds like the insurance coordinator is trying to appeal just so she doesn't have to admit she never verified to begin with. I don't see how she can appeal an excluded benefit. If they bent the rules for one they'd have to for everyone and unfortunately insurance companies don't work that way. Maybe you could show the research to your company's HR department in hopes of making it a covered benefit in the future.

[Ms.AntiBand 2,984]

Yep.. Know how you feel. My insurance completely excludes ANYTHING to do with WLS. This is the policy our employer contributes towards (along with our $700+ monthly premiums) so thy have the say so. It doesn't matter what insurance co you go through when the employer has the say on the policy. The policy states exclusions and that's the policy bought.

I have Blue Cross and vast amt of people on this ovum are being cover through them... Because that's the policy thy have.. But not me. Sucks big time.

I went to MX and have for many surgeries and personally if my insurance did pay and would do OOC coverage I would seriously still considering going there. I like my dr and trust him and the hospital and clinic.

Good luck and I'm sorry you have to hassle with all this crap.. Been there, done that, at a cost of near 100 grand

[SweetnCurvy 112]

Mine was not coved either. Talked with the hubby' date=' he asked how much would it cost for us to pay. He stated, "We could do that". Now I'm post-op. Definately got the secondary insurance. I drive a 12 year old Jeep, instead of replacing it soon, we invested in me. I'll be the sportscar![/quote']

WOW what a great husband...he is definitely a keeper:)

[SweetnCurvy 112]

Supposedly' date=' they did. She told me she had the name of the person who verified coverage too.[/quote']

That is awful, sometimes those reps can be so confusing:/

[SweetnCurvy 112]

Not to be a downer' date=' but it sounds like the insurance coordinator is trying to appeal just so she doesn't have to admit she never verified to begin with. I don't see how she can appeal an excluded benefit. If they bent the rules for one they'd have to for everyone and unfortunately insurance companies don't work that way. Maybe you could show the research to your company's HR department in hopes of making it a covered benefit in the future.[/quote']

I agree, an attempt to cover her own butt

[SweetnCurvy 112]

I just got off the phone with the insurance coordinator' date=' and she's fired up and moving to appeal, peer to peer, etc. I pointed out about my employer specifically excluding it, but that didn't discourage her. She's also going to send me an article with recent statistics that I can use to fight on my end with Corporate HR.[/quote']

Omg...good luck

[iggychic 1,405]

I don't know how big your company is, so I don't know if this helps. First, we are self insured, which means we pick and choose within federal and state guidelines, what our employees have covered. We don't do this to provide the least coverage, but instead to offer the best as a competitive advantage. So with that in mind, we listen to our team when they say we are missing the boat on things like this. So if your company is slightly manageable (less than 1000 people) don't talk to HR, talk to the owners and ask them to consider adding this coverage as a benefit for their staff.

And then there's the situation you're in....I will tell you that the HR dept can't add coverage we haven't chosen. We also can't just add it willy nilly...we have to be in a period in which we can make changes unless we've been shown we are violating state or federal law. We also can't cover something for one person and not cover it for all, so there is no appealing a non-covered item. No appeal will make that happen because we have to be fair to all of our people. I only share this because I don't want some uniformed HR person to get your hopes up when there isn't hope at this point The only way you can appeal a denial is if it's a covered item you were denied for whatever reason (providing compensating information to offset the denial).

I wish you the best. If I were your employer I'd want to know how you feel about this.

[ArcusX 216]

I don't know how big your company is, so I don't know if this helps. First, we are self insured, which means we pick and choose within federal and state guidelines, what our employees have covered. We don't do this to provide the least coverage, but instead to offer the best as a competitive advantage. So with that in mind, we listen to our team when they say we are missing the boat on things like this. So if your company is slightly manageable (less than 1000 people) don't talk to HR, talk to the owners and ask them to consider adding this coverage as a benefit for their staff.

And then there's the situation you're in....I will tell you that the HR dept can't add coverage we haven't chosen. We also can't just add it willy nilly...we have to be in a period in which we can make changes unless we've been shown we are violating state or federal law. We also can't cover something for one person and not cover it for all, so there is no appealing a non-covered item. No appeal will make that happen because we have to be fair to all of our people. I only share this because I don't want some uniformed HR person to get your hopes up when there isn't hope at this point The only way you can appeal a denial is if it's a covered item you were denied for whatever reason (providing compensating information to offset the denial).

I wish you the best. If I were your employer I'd want to know how you feel about this.

Hi Iggy,

I think you are spot on. I work for a Fortune 400 company $8.78B in annual revenue. I understood from the get-go that the company's decision not to cover WLS in any of its medical insurance offerings was purely negotiating a lower premium. I don't know what the statistics are, but I'd be willing to guess that there's a very small percentage of people who even consider WLS as an option, and likely those who consider it, give up after finding out that it's not covered. I would have, if I hadn't already gone through all the pre-op stuff.

Having said that, it sounds like you may be a good resource to advise how I might proceed with at least giving my feedback to my employer's HR department. I've been thinking I would write a letter to the SVP of HR, opening with something like, "How many morbidly obese 80-year-olds do you know?" Probably not many. Then go into pointing out statistics, and finish up with urging them to reconsider their decision that was made a long time ago based on data that is probably 10 years old, relative to complications and their claim costs, vs. the benefit. I'm not afraid of doing that, but moreover, I hesitate to leave this in the hands of just one person. In other words, I feel like an executive both in and outside of HR should hear the information.

How stupid would that be?

[lose2win 32]

I have Aetna and I was fully apporoved

Sent from my iPhone 5 using VST

[iggychic 1,405]

Hi Iggy' date='

I think you are spot on. I work for a Fortune 400 company 8.78B in annual revenue. I understood from the get-go that the company's decision not to cover WLS in any of its medical insurance offerings was purely negotiating a lower premium. I don't know what the statistics are, but I'd be willing to guess that there's a very small percentage of people who even consider WLS as an option, and likely those who consider it, give up after finding out that it's not covered. I would have, if I hadn't already gone through all the pre-op stuff.

Having said that, it sounds like you may be a good resource to advise how I might proceed with at least giving my feedback to my employer's HR department. I've been thinking I would write a letter to the SVP of HR, opening with something like, "How many morbidly obese 80-year-olds do you know?" Probably not many. Then go into pointing out statistics, and finish up with urging them to reconsider their decision that was made a long time ago based on data that is probably 10 years old, relative to complications and their claim costs, vs. the benefit. I'm not afraid of doing that, but moreover, I hesitate to leave this in the hands of just one person. In other words, I feel like an executive both in and outside of HR should hear the information.

How stupid would that be?[/quote']

I am sorry you have to be the advocate at the company, but happy to hear you want to be.

So I think your approach is great. If you can find some data on the costs associated with obesity and health care of people within the age range of your average employee as well that might be helpful. When it comes to the costs of health care they will weigh the costs of the surgery against the costs if someone does not have the surgery, so something that covered the percent of americans who are obese and the costs of obesity in general would speak volumes against the cost of the surgery which is relatively inexpensive. Adding your own personal costs like medications etc if there are any wouldn't hurt as well.

A company of that size is going to be focused on the numbers and nothing else likely. We are not that large and as such, we focus on both the numbers, but also on being competitive. In our industry being competitive means we offer the best package possible and so when we see a deficiency we make an effort to fix it.

One other thing I didn't mention, but should is that you should check out your state laws in regards to this care as well. Our coverage was part of a general package covering the highest requirement in one of the states we do business in. But as it turns out, it wasn't that good of coverage. Large conglomerates sometimes miss changes in state laws that require levels of coverage for some services. This is a rapidly changing field and if your state requires a certain level of coverage, yet they haven't changed their policy (which has to be done when the law is in effect, not at a renewal period) they will make the change right away if it's pointed out to them.

I personally ran into that with a large bank I used to work for many years ago. When I pointed out the issue it was sent for review and fixed for all employees within the week. They do this obviously to cover their behinds But sometimes those sorts of things are missed and need to be presented to get the change done.

I find it odd that this gal in HR (in a company of that size) would be doing what she's doing which makes me wonder if they really don't offer WLS coverage...of if its on an approval basis only. If that was the case an appeal would make sense. If it isn't and they offer nothing, she could lose her job for offering to send this up the flag pole as it sort of leads on the employee in a bad way (as you know given you've spent a considerable sum already because you thought it was covered). I would certainly not leave this in her hands alone, but when you send the letter, CC her so that she's made aware of it (so you don't lose an advocate) but also so that if she is needing more training (my nice phrase for what I'm really thinking) they can address that and the situation they've put you in as well.

I wish you the best with this. We care Our coverage has changed many times because of our personal medical experiences and our team's. We, like this company you are with, look at every bill that's denied and reassess where we are. They do it a bit differently But we all still look at the bottom line and our effect on that.

BTW...if you are in a highly competitive field and recruitment is a challenge for the company (ie engineering...oil and gas, etc) than add the value of this on a moral basis as part of your letter. But if you're in something like say banking...that's sadly not going to be the focus, so just stick to the costs.

Hope that helped!

[Wolfgirl1978 256]

I feel your pain. I have BCBS, but my employer has a WLS restriction. No how, no way, no matter what. I know that a lot of people go to Mexico because of the price, it scared me too much. I took out a loan from my credit union, my surgery cost me $14,000. I pay a $350 a month note for 4 years. Best money I've ever spent.

[amitch17 17]

I feel ya. I was denied in Ontario (unless I want to wait 3 or more years and go through ohip). So I am going to Mexico and paying out of pocket. I'm fortunate enough that my fiancé is paying for me. But to those who don't have that kind of money just laying around you could always look into financing or a line of credit (low interest). My fiancé only makes $65,000 a year and he got approved for a $35,000 line of credit. So I'd go talk to your bank.