UHC-excluded from policy

[hburgess 0]

I have UHC and they are telling me the bariatric surgery is excluded from my policy. Is there any hope in trying to submit it and appeal it or am I out of luck. My PCP tells me there is no reason for me to be denied because of my weight and health history. Just wondering if anyone else has been down this road..

[GreenChrysalis 1]

Hey there. I have UHC also, with a WLS exclusion policy. This is a decision made by my husband's employer. I could have tried to lobby with them to get them to change, but I didn't really want to wait to see if that happened. So I am self-pay. From what I understand, it's difficult get the surgery approved when there's an exclusion (as opposed to appealing when you have been denied). But perhaps someone who has been there will tell you differently. I see a lot of people reference ObesityLaw.com so perhaps they could assist you too.

[kcispy4 0]

Hi. I work in insurance and it is all in what the company you work for elects when they purchase their policy from the insurance company. Unfortunately,I don't think you will be able to win an appeal because the premiums the company (and employees) pay are based on the coverages elected by the group. So basically they won't cover a surgery that you haven't paid premiums for. I hope you work something out. UHC is usually great about approvals as long as the policy includes the procedures. Good luck.

[Wheetsin 714]

I have UHC and they are telling me the bariatric surgery is excluded from my policy. Is there any hope in trying to submit it and appeal it or am I out of luck.

Find out if it's a policy exclusion or an employer-elected exclusion. You can usually get this information from an HR rep or your SPD (summary plan description - the huge booklet you get that details what's covered).

Some people have had luck when it's a policy exclusion (that's not the technical term, maybe someone can help with that) -- but when it's an employer-elected exclusion there's not much you can do. It would be like not paying for a warranty, and then expecting warranty work.

[Wheetsin 714]

Some other posts that may help:

Insurance question........

Anyone with United Healthcare get LB?

Can you appeal if there is an exclusion?

Insurance Covers , But Employer Excludes?????????????

And from a post I made a while ago:

This is my limited understanding as it applied to the general insurance world.

If the employer has specifically excluded the coverage, then there is nothing to appeal unless you wanted to write a letter of appeal to the employer asking them to consider changing their coverage for you, which they won't, because it's something they do to reduce premiums. Appealing to the insurance company does nothing because it's not something the employer has purchased. That would be like if you bought a base model car from a dealer, then complained to the manufacturer that your car didn't have a sunroof.

IMO there's nothing to hire an attorney for. It's 100% up to an employer what coverages they want to purchase and what they don't. There's also no discrimination in it - what coverages an employer opts to purchase is 100% that employer's business. Not choosing to buy WLS coverage isn't discrimination against the overweight anymore than a $50 copay is discrimination against people who don't have $50. They aren't doing it specifically to treat you any differently... there's no discriminatory intent there. Some employers have incurance policies that exclude x-rays, but they aren't discriminating against people with bones. :eek:

Not good news, I know - but when the denial comes b/c it's an employer exclusion, there's not a lot of room to play with. If the insurance company denies you, you have a lot more room and substance for appeal.

[CajunDisney 0]

ok. reading this makes me nervous. my doctor told me the other day that UHC was really good about paying for LB. I hope I don't run into any problems.

[GreenChrysalis 1]

Well, unless your doctor is familiar with your employer's specific coverage, I wouldn't take his or her word for it. My GP said the same thing -- "oh, I believe UHC covers it" -- but didn't realize that my specific policy did not. I'd suggest contacting your insurance company directly as well as your HR rep and find out before you get too far into the process. It was disappointing to find out that my husband's employer excluded it, but I'm glad that I found out before I really got started.

ok. reading this makes me nervous. my doctor told me the other day that UHC was really good about paying for LB. I hope I don't run into any problems.

[CajunDisney 0]

well, I just looked at my benefits online and it doesn't look like it will cover it. *&&*^%$:regular_smile:

My main benefits page says it is excluded, even for medical reasons. HOWEVER, there was another resource for United Heatlh Resources that provides some sort of assistance (not sure to what extent) with bariatric treatments.

Anyone had any experience with this?

Going to call my GP tomorrow and see what she says I should do.