insurance coverage

[cathrine1013 0]

I have medical insurance with my job.

On through evidence of coverage letter it says weight loss surgery covered if you over X bmi or you have at least 2 of x health problems, I fall into both, so I make an appt to see a doctor, today the doctor calls and ask me if I want to keep appt because my insurance will not cover any weight loss surgery.

I call insurance company with evidence of coverage in hand, speak with a nice lady that tell me it is excluded from my policy, I read her the page and give her page number, she goes to tell me that is incorrect and will not be covered. What can I do? Can I force it to be covered since I have in writing it is? If it was not covered I would have never took the policy, would have got private insurance.... just kinda lost and not sure who I need to talk too?

[alamergrl 8]

contact your HR dept at work. they should be able to tell you if it's covered by the policy they purchased.

[ChristyAZ 87]

You can file an appeal if hey still refuse to cover it .... however you may have to go through with the initial appointment and have the authorization denied first .... the only problem there is that if the surgeons office knowingly submits a authorization just to get a denial they may not be able to help you with the appeal .... I would call the authorization specialist at your surgeons office and ask what your next move might be ....

[terrydumont46 1,954]

I kept my appointment just to get the denial so I could appeal. I don't know what a insurance company has to do to change their coverage. you can also involve your insurance commissioner of your state. they may have your answers and maybe of help. I was once denied gyn surgery because they said it was a pre existing illness. I wrote to my insurance commissioner and they had a talk with my insurance company. the decision only took a week. insurance companies don't like the commissioner involved. I wish you lots of luck

[Happymom8992 6]

I have personally fought insurance company before and won after 3 denials ! Don't give up and don't take no for an answer. Take matters in your own hands...build your bullet proof case and appeal . 9/10 it will get approved I was told and am living proof good luck

[kimk1999 450]

Definitely talk to your HR person at work. I'm definitely not an expert, but there's a chance your employer could have opted out of this part of the coverage to save some money. Did you find the coverage page once you logged in and went to see your coverage? Or did you find that wls was covered generically by that insurance company.

[Gardnergirl2 96]

Everyone has given good advice. I deal with this kind of stuff all day every day at my job. First of all, make sure you looking at a 2014 SPD (summary plan description) suited for your employer (I know larger companies have these-smaller companies I am not sure- ask HR at work). If what you are looking at in writing is current, they can't really deny you. They can deny you if you don't qualify, but they can't pop up and say "we don't cover that".. Here's what you do:

1. Call the insurance company and tell the rep you are confused bc you have written documentation that they do cover it. See what he or she says (old document, so on, so forth)

2. No matter the answer, talk to HR at work. See what they say. Ask if there is a copy of the 2014 SPD that you can have (preferrable electronic verson for easier searching). See what it says.

3. Don't give up. If you qualify, and know that you are looking at a current document, appeal. Talk to a supervisor. Talk to your Benefits Advocate if you have one.

4. Post here. Many of us have been through the landmine of insurance and are happy to try to help