Hubby's Employer Excludes WLS. What now?

[chloemom 0]

Just got off the phone with my hubby's employer (who health insurance is through). They have specifically excluded weight loss surgery from coverage. What do I do now? Anyone else been in this boat? The Insurance is through UHC. :confused2:

[HarleyGirl 1]

I can't speak to the specific insurance, but our policy also has a written exclusion to WLS. My understanding is that there is no way around it. The doctor's office said there isn't any way to challenge/appeal with an exclusion. Consequently, I am a self pay!

[chloemom 0]

I read somewhere.. that the employer might be able to submit an exception on a specific case or submit a rider or something. I am trying to look into it. Hubby and I are buying a business and really cannot afford the whol $15,000 right now.

[emmaluvu 0]

Unfortunately I am in the same boat you are. I have UHC and my plan specifically excludes WLS. Being that I have to self pay I've decided to go to Dr. Ortiz in Mexico. Surgery costs $8,000 versus the 15-20 grand here in the states. Research the doctors more and you'll find lower cost options. You will see that there are very competent and expertly trained doctors in Mexico. Review the posts on the boards and see for yourself.

Good Luck!

[Wheetsin 714]

What do I do now? Anyone else been in this boat? The Insurance is through UHC. :confused2:

Hate to say it, but start saving for self pay, or (if you're employed) start looking into your own benefits.

Employer-enforced exclusions really only have one way out - to ask the employer to consider purchasing the coverage. I can't think of any employers I know who would do this for one person, but I guess you never know.

If it's the carrier refusing to cover, you have a little more room to play with. But in this case, it's basically a matter of not having it because it's not being paid for. Getting the company to pay for it (add it to their plan) would really be the only way around it.

[Wheetsin 714]

You as a customer (well, customer's customer since your employer is their customer, not you) can't submit a rider. Rider (contract rider) is, long story short, the documentation used for a clause to change a contract. Think of it like an addendum or ammendment - a document that effects some change to the original contract.

HTH

[chloemom 0]

I spoke to the True Results Center I would be going through. They said I can request his employer to add it to my coverage. All hubby's boss would have to do is call the insurance company and tell them to cover it for me. That's it. Hubby is tight with his boss so he is gonna try to get him to call. I also have an emotional letter (True Results idea) ready.

Keep your fingers crossed!!

[Wheetsin 714]

If they'll do it, more power to you. But they didn't tell you quite right. They don't just call and ask to have it added, they call and ask and then have to pay for it. A large employer- that's probably not going to happen. But if your husband works for a smaller place, and/or has some pull with the HR decision-makers, then there's a chance. Hence the "...really only one way out... ask the employer to consider purchasing the coverage" I mentioned earlier.

Good luck/best wishes - hope your husband can Rico Suave someone! :mad:

[faithmd 14]

I second what Wheetsin said.

Not so simple as calling as saying "cover it." It involves $$.

But I am keeping my fingers and toes and everything crossed for you!

[chloemom 0]

Well I know it is going to cost. It won't be as much however as covering everyone if they cover just me.

[faithmd 14]

Gosh I wish I knew more about how the whole group insurance thing worked (where's Alexandra...), but I don't think they can add a rider for only you. I believe it is a rider to their entire policy. Could be wrong, though.

Please keep us posted, I hope it works out for you!

Keep in mind the Mexican or the US surgeons that offer good prices on package deals that are less than $12K and many less than $9K, just in case this doesn't work out. Dr. Kirschenbaum in Colorado has a package for an excellent price. There's a few threads here about him, and lots of threads about Mexican surgeons.

[Wheetsin 714]

It won't be as much however as covering everyone if they cover just me.

I know we aren't telling you what you want to hear, but you asked and we really are just trying to help.

From whom are you getting your info that the company can just up and change their exlcusions, just for you/one person??? You may want to seriously question whomever it is.

I've been associated with the insurance industry for several years, and I've never seen it work the way you're describing. By "it" I mean an exception being made to a policy for just one person, for something like WLS. The only time I've seen anything even close to that has been in situations of unique and extreme disabilities, and even then it was a fight. For your every day stuff, every employee receives the same benefits and exclusions affiliated with their elected plan.

[Wheetsin 714]

No Faith, you're right. Riders change contracts, not individuals.

[Wheetsin 714]

Come to think of it, I know nothing of contract law, but I would think that making an exception for just in person, outside of cases of extreme and unique disability, would be grounds for a lawsuit on behalf of all the others for whom the exclusion remains in-force...

[Wheetsin 714]

Alexandra would be a good one to chime in, she knows way more about the industry than I do. I'm on the outskirts & not directly involved with brokering, underwriting, etc.