Is there anything legal that I can do????

My Life Back · January 12, 2008

I just started my new job a little over 90 days ago. My company is huge (over 4,000 employees in 130 countries). They are a Self-funded Insurance with a third party administrator. We use MultiPlan as our provider and Allied Benefit as the administrator. (At least I think this is how it goes....lol)

In my Offer Package was a copy of the "Medical Benefits Plan Schedule of Covered Expenses". On this sheet, the coverage reads:

"Surgery or treatment for MORBID OBESITY only if the covered person is twice his/her ideal weight or greater than 100 lbs overweight and suffers from documented seperate conditions (i.e., severe diabetes, mellitus, hypertension, cardiovascular complications, obstructive sleep apnea, hypertriglyceridemia, amenorrhea, hypercholesterolemia, degenerative joint disease, & athralgia of other weight bearing joints which are aggravated by morbid obesity). This must be documented by objective evidence provided by the physician who is treating the covered person for the condition that is aggravated by morbid obesity. This does not include gastric bypass surgery (i.e., "stomach stapling")."

In-Network: 100% ($25 co-pay if outpatient) :tongue:

Well, I recieved another copy of this stated coverage in my New Employee Orientation....so I ASSUMED that Lap Band would be covered.

So I started my journey. (Now keep in mind, this is all x2 since my DH was planning on having surgery with me.)

I began researching the area doctors, and found this site.

I saw my PC and told him I wanted the surgery - he agreed and approves of the procedure and sends out the referral. $25

I asked him for current blood work - he sent me. $??

I sought out a psychiatrist for the Evaluation - found one, had her 3 required visits and "passed" the evaluation. $75

Now I have completed the "hoops" for the surgeon and was waiting for my appt. with him. So, now I am sitting at work daydreaming about the surgery and think that I will be nice and try to keep the ball rolling at the unbelievable pace that it is and send a note over to the surgeons office (as I was told I could do to help expedite the paperwork) that says my insurance doesn't require the diet history/supervised diet. :wink: I decide to send a copy of this "Schedule of Covered Expenses" along with the letter.

I go to the website the website that I can print my coverage info from and print a copy of the schedule that is posted on their website and get the shock of my life when I re-read it and find out the VERY LAST SENTENCE in the coverage has changed!!!! Instead of reading that gastric bypass is the only thing not covered, it now reads:

"Note the term "treatment" does not include any surgical procedures - see General Limitation, item #17".

#17 - This policy does not pay for instruction or activities for weight reduction or weight control, including charges for Vitamins, diet supplements, or physical fitness programs even if the services are performed or prescribed by a Physician; for any surgery performed for the purpose of weight reduction.

WOW!!! What a shocker!!! The page that says no surgery is covered says Revised 1/06 on the bottom - the other pages I have don't have anything written on the bottom!

So, first things first - I head straight to my HR department. They have no idea, so I am walking them through the details step by step. They tell me they will get back with me. :wink:

She comes back a little while later and tells me that she called someone (within the company) and was told that they would reimburse me for my costs of preparing for the surgery, but that surgery isn't covered. The page printed from the internet is correct :eek:!!!!

I called the insurance company and talked to a lady who was very helpful - she told me that I could send a letter to the medical review board and that I needed:

1 - Letter from surgeon

2 - Current and reccomended weight

3 - CPT codes and the fee for each procedure

4 - 6 month supervised diet

They didn't even ask about BMI, co-morbidities, etc.

My head is just spinning!! Is this a positive sign or a so-called death sentence?? I don't know what to do.

I don't want to take the reimbursement and then them say "well, since we reimbursed you, it was like you agreeing that there is no surgery" or something screwed up like that.

Sorry for making this so long, but I am just on a roller coaster about all this.

Any input would be greatly appreciated. I don't even know if I should try. :frown:

minpinmom · January 12, 2008

Wow, I am so sorry you are going through this. What a nightmare. I wouldn't take the reimbursement . . . yet. I would go through the appeal process and contact a lawyer to see if you have a case about the way they hired you. I think that if you are offered something when hired, and accept, your company can change in the future, but they can't offer you benefits that weren't available. Quite a few years ago I was hired, part time at a job and they offered me holidays off, the company changed that a few months later, (only available for full time) I threw a fit and got to keep my holidays, because I said it was part of the reason I took the job. I also threw the word ACLU around a lot. I know it is not the same thing, but it made me think of it when reading your post. Good Luck and please keep us posted.

nursekathy2u · January 12, 2008

I think you misread the last sentence. I think they are saying the word "treatment" doesnt mean surgical treatment is excluded, only medical treatment. What it says to me is that they do not pay for any medical treatment of morbid obesity including the things they require you to have done in order to get approved for surgery. It is very common for insurance companies not to cover anything to do with treatment of morbid obesity EXCEPT for surgery. If you want to be sure call your insurance company and ask them if Lap Band Surgery CPT code 43770 is covered. Good Luck!

Kathy

My Life Back · January 12, 2008

I go to the website the website that I can print my coverage info from and print a copy of the schedule that is posted on their website and get the shock of my life when I re-read it and find out the VERY LAST SENTENCE in the coverage has changed!!!! Instead of reading that gastric bypass is the only thing not covered, it now reads:

"Note the term "treatment" does not include any surgical procedures - see General Limitation, item #17".

#17 - This policy does not pay for instruction or activities for weight reduction or weight control, including charges for Vitamins, diet supplements, or physical fitness programs even if the services are performed or prescribed by a Physician; for any surgery performed for the purpose of weight reduction.

I just noticed that the JUST the last sentence has changed, but they took the first word of the definition that says "surgery" or treatment....... now it just starts off saying:

"Treatment for Morbid Obesity....."

Thanks for the insight Minpinmom - I also thought about throwing a fit, cuz in my gut I feel like that is the case. I feel like they know that if I throw a fit, they will have to cover it. It was strange bcuz all this went down on Tuesday and yesterday, the same HR girl, saw me in the coffee room and asked me about my receipts. Then made sure she let me know that she had discussed it with her boss (the director of HR) and that she agreed that they would reimburse me.

I felt like that was her way of trying to convince me that there is no one that I can talk to to argue about it with.

nursekathy2u - THanks for the info. I just called and this is what the lady told me: "Still move forward with having your Dr. send in the pre-determination paperwork....especially if you still have a copy of the so-called "wrong" coverage."

So to me she is telling me that if I fight it, I still may be able to have it covered.

That is a bright spot for me, however, I was not looking forward with fighting the insurance company.

Now if my company is Self-funded, does that mean there is some kind of medical review board within my company that goes over this stuff. I would be totally humiliated to know that my bosses knew when I am thinking I am doing this on the down-low.

Anyway - Thanks for the posts ladies. I appreciate it. I just wish I knew a lawyer to tell me if I had a leg to stand on with this before I go and fight about it.

Being new to the company, I don't really want to rock the place, but I WANT THIS SURGERY!!!!

QTkidsmom · January 12, 2008

I am a Manager for a Managed Care Plan, I get paid to read and understand this stuff and have for almost 20 years.

I do not believe that they are reading this correctly. The first statement indicates that they will cover WLS when certain criterian are met. The exclusion is very typical of any insurance document. They will not cover the surgery solely for the purpose of losing weight (in other words, to improve appearance, even if it is doctor supervised).

I think that you have a very good chance of coverage if you go through the process described from the agent at your insurance. At this point, this does not sound like an appeal because I did not read that you were denied yet. No denial, no appeal. You can fill a grievance with your health plan without a denial and sometimes that helps to clarify but they usually get things a little confused about who you are grieving against, that may disrupt your relationship with your surgeon's office since they will likely assume you are grieving about their practices or information they provided. You can maybe avoid confusion by clearly stating the concern in the grievance and alerting your surgeon's office of what you are doing and why.

Hope this helps. God Bless you in your journey.

My Life Back · January 13, 2008

QTKidsmom -

The coverage that they are now saying is valid is:

"Treatment for MORBID OBESITY only if the covered person is twice his/her ideal weight or greater than 100 lbs overweight and suffers from documented seperate conditions (i.e., severe diabetes, mellitus, hypertension, cardiovascular complications, obstructive sleep apnea, hypertriglyceridemia, amenorrhea, hypercholesterolemia, degenerative joint disease, & athralgia of other weight bearing joints which are aggravated by morbid obesity). This must be documented by objective evidence provided by the physician who is treating the covered person for the condition that is aggravated by morbid obesity. Note the term "treatment" does not include any surgical procedures - see General Limitation, item #17."

General Limitation #17 reads -

No payment will be made under this Plan for expenses incurred by a Covered Person: for instruction or activities for weight reduction or weight control, including charges for Vitamins, diet supplements, or physical fitness programs even if the services are performed or prescribed by a Physician; for any surgery performed for the purpose of weight reduction.

Can you still decipher that it will be covered? I am seeing that it says there is no coverage for ANY surgical procedures. (The last sentence)

You have given me hope :myscared: - but I am not sure if you read the right coverage paragraph from below....I am praying that you are right, but I am soooo skeptical. I just keep waiting for my balloon to be busted into many little pieces. :redface:

Thanks so much for helping out.:smile:

QTkidsmom · January 13, 2008

That is all just double talk...they have really excluded all known "treatments" for morbid obesity in line 17. I still believe that the fact that they have stipulated that treatment for morbid obesity is covered when certain criterians are met, and the fact that if your doctor documents that the WLS is to treat the co-morbidities not the specifically the obesity itself, you have a good chance of coverge.

That sounds confusing but basically, they do not want to pay for you to simply lose weight. They are likely to cover a surgery that will potentially reduce future cost the will be responsible for to treat the co-morbibities. Diabetes, heart conditions, sleep disorders and the such are all very costly to treat. That is the angle that you need to emphasize. The fact is that they know you losing weight is your best chance at improving or eliminating risk of needing treatment for these co-morbidities. If you can establish that you are unable to lose the weight without this tool, they will have a vested interest in paying for the surgery. That is why they are asking you for the documentation that they have.

Don't forget, if they deny you, you will have appeal rights. You have an earlier version of you policy that indicates they would cover it. That may end up being the smoking gun in your pocket.

Just give them what they are asking for, don't accept reimbursement for the expenses that you have already paid, unless you are denied and lose an appeal. The main reason I believe that they would deny is if you do not meet the criterian they stipulated. A good point to remember is that the plans CAN and often DO pay for services that they have listed as an exclusion, they CAN and WILL be sued for not covering what they say they will.

If it comes to appeal, let me know, if you would like help writing it, I will do my best to help.

God Bless!

My Life Back · January 13, 2008

Wow!!! I like the way you read things :myscared:

I can only pray that the person responsible for my approval has an understanding of the coverage as you do.

That whole thing about it being more cost efficient in the long run to pay for surgery vs. all the health problems is EXACTLY what I was thinking. I think that on top of all the medical bills they will be paying for BOTH me and my DH, it would be better to cough up the surgery for both of us than to have to pay out for all the medical bills AND the huge life insurance policy that I took out on us, should one of us drop dead (god forbid!) from our health problems. :smile:

I appreciate all you have done for me thus far!! You have brought a whole new light to the topic for me.

I was very down and depressed thinking that we were not going to get surgery at all....and now I can see it from the point of view that your giving me and that gives me hope again that we can get our surgery and finally get healthy!!

I was telling my DH earlier that I didn't think I would take the reimbursement until I got denied 2 or 3 times....ya know, when I thought it was really NOT going to happen....lol.

I can also see that the first hurdle we will have will be the supervised diet. I don't know if or how we can get around that.....we may just have to go with it....and that kinda sucks. But after that, we will have all the info she told me I needed to send in and then some.

I would love your help writing an appeal letter - hopefully it won't be necessary.

I plan on calling the surgeons office on Monday to move forward with the appt. They should already have our blood work (although I am sure they don't) and hopefully they will have the psych evals by then too!! Then I believe all I need is the referral from my PC and I get an appt with the surgeon!! Wooo hooo!!

Thanks sooooo much for giving me hope again!!! :redface:

QTkidsmom · January 14, 2008

Not a problem at all...I hope that things go smoothly for you and your husband! That is awesome that you are able to do this together.

The important thing is to not lose hope, at this point it is all you have. Stick to your guns, do all that they ask, and you should be able to convince them that this is worth the investment.

One thing to consider about the supervised diet is that a lot of carriers will accept past attempts, that have been documented. That means if you ever followed Weight Watchers, Jenny Craig or the type, you might want to check if they will accept those records.

God bless!

ForwardLeap · January 14, 2008

I am so sorry, what a stressful situation! I have heard so many struggles with Insurance companies. The thing that really gets me is if you need help to get to a healthy weight so you can possibly prevent alot of medical conditions that will require the insurance company in the long run to pay even more $ out--you should just be allowed to get the WLS!

What really is frustrating is that people who are able to get (is it Medicare, or Medicaid that will pay for it) the government to assist them, yet insurance companies do not have to cover others!?? Is something not wrong with that?

It surely feels like discrimination? Why should one person the same BMI, co-morbidity's, ect.. get help and another be denied?

I would appeal and send them everything the lady you spoke to requested. Keep contacting the same lady if you can. Every time you send something give her a quick call and say I am putting this in the mail, or I just faxed over to you....maybe by building some sort of a relationship with her she will help you get in touch with the people you need to speak with?