Denied due to exclusion in policy!

Dee66 · April 25, 2008

Hi everyone.....I am writing this entry with tears in my eyes because after almost 7 months of doing EVERYTHING I was told to do, I found out today that I was denied for surgery due to an exclusion my employer has on my policy regarding weight loss surgery! Now, I am a little confused because I have never received anything from my employer with a list of excluded services. I wonder what else is hidden that they are not telling me about? When I first started this journey, I called BC/BS of NJ and asked not one, but three representatives if bariatric surgery would be a covered item under my plan and ALL 3 of this num-nuts told me "Yes, as long as it can be deemed medically necessary and that you are morbidly obese"! Well, got those both covered so imagine my surprise after I spent almost $1000 on all the doctors necessary at $30 a pop since that is my co-pay!

I really don't know where to go now. I did contact my HR director at work so that she could provide me with an up to date insurance booklet. The last one I requested in 2007 and I got a 2005 copy!

If anyone has any helpful information, please let me know because if I keep going the way I am going, I will be huge and will most likely not need LB anymore, I'll be looking at a GB! THanks so much

gone 4 ever · April 25, 2008

Dee,

I am so SORRY. I would talk to my HR person and ask them to show you the exclusion and thell her what BC/BS told you. there might be a way around the exclusion.:crying:

Long2BFree · April 25, 2008

I am so sorry that you are having to go through this. You have every right to be so upset. I agree that I would contact the HR office and get more info about exclusions. Ask them when all of this info was supplied to the employees. Get everything together as far as when you called your insurance to find out out about bariatric surgery, get your receipts together for your appointments and write everything done showing a timleline. I would then fight being denied, because it sounds like your company was negligent in supplying you proper information but BC/BS also told you it was a covered benefit three times.

Miss Polly · April 25, 2008

Dee66,

Sorry to hear you are in the same boat as I was. My employer did not op to pick up this benefit due to the cost of the additional coverage. I was desperate at 375 lbs. 5'6" and on a downward spiral, as far as my health is concerned. I made a tough decision to cash out some of my retirement fund and go to Mexico to have the surgery. I may never reach retirement age if I hadn't had the surgery! I found out that having the surgery in the U.S. would coast around $1800.00 and in Mexico it was just 7000.00 I did my homework and studied about the Mexican doctors and found a wonderful dr. in Monterrey that was great. After surgery, I did have a tough time finding a fill doctor in my town but I persisted and find one just a mile away.

Don't give up, if you really want this surgery, God will open a door and provide you with a means to do it. I have no regards about having the surgery done in Mexico and would do it again if I had too.

Hope this gives you a little hope and remember you are worth the effort!

Miss Polly:rolleyes2:

RHS · April 25, 2008

I am so sorry to hear that..any chance of self pay? I have BCBS of NJ too I called when I started in January and they said I have a gray area in my policy and they could not tell me a yes or no..until every thing has been submitted. I am coming up on my 5th month so 1 more to go and I will see..

Dee66 · April 25, 2008

Thanks everyone for your info. I did go through my booklet with a fine tooth comb last night and did find in the back a section of "Exclusions". However, under weight reduction/control it did clearly state that unless there is a diagnose of morbid obesity...and there is!! I have to call the Doctor today and ask what diagnosis they wrote. I have a fight on my hands however I am willing to do this and this insurance company will not know what happened to them!!! I won't give up and I thank you all for your help. I will keep you posted.

KayKay · April 25, 2008

Keep Fighting And Don"t Give Up!! I Am In A Battle With My Insurance As Well! I Hope You Get Good News!!!!!

Dee66 · April 29, 2008

Hi everyone! Since my last post I have done some leg work on this exclusion in my policy. I was told to contact my HR director at work and speak to her. I really didn't want to go this route since I was trying to keep it private. She is a really nice and helpful person and I knew I could talk too her. I explained what was going on and she said she would put me in touch with the broker who my employer goes through for health insurance. I had to wait the entire weekend which felt like an eternity! On Monday, the rep called me and we went over EVERYTHING I was told and all my diagnosis's. She told me she would look into it and get back too me. Today, Tuesday, I called her to see what the status was and she said they are still checking into things. I am keeping my fingers crossed and saying my prayers that this comes back with something positive. I was told by the doctors office that sometimes employers have been know to remove that particular exclusion from the policy. I have been with the company for over 17 years and have good relationships with the owners and management. I really need to get this for so many reasons but the most important one is for my health. I have high blood pressure, a BMI of 44, onset diabetes and sleep apnea! What the hell more do they need? Gotta love Horizon BC/BS! Maybe I actually will!

gina0922 · May 2, 2008

Hi everyone! Since my last post I have done some leg work on this exclusion in my policy. I was told to contact my HR director at work and speak to her. I really didn't want to go this route since I was trying to keep it private. She is a really nice and helpful person and I knew I could talk too her. I explained what was going on and she said she would put me in touch with the broker who my employer goes through for health insurance. I had to wait the entire weekend which felt like an eternity! On Monday, the rep called me and we went over EVERYTHING I was told and all my diagnosis's. She told me she would look into it and get back too me. Today, Tuesday, I called her to see what the status was and she said they are still checking into things. I am keeping my fingers crossed and saying my prayers that this comes back with something positive. I was told by the doctors office that sometimes employers have been know to remove that particular exclusion from the policy. I have been with the company for over 17 years and have good relationships with the owners and management. I really need to get this for so many reasons but the most important one is for my health. I have high blood pressure, a BMI of 44, onset diabetes and sleep apnea! What the hell more do they need? Gotta love Horizon BC/BS! Maybe I actually will!

Hi Dee,

I will definitely have to keep up with your journey with Horizon BCBSNJ as I have them as my carrier also. I spoke with a rep from the ins comp myself and was told it was excluded unless it is medically necessary. I called my HR person because I wanted to know exactly what the insurance would require of me such as the 6 mo Dr supervised diet (secretly hoping they would say, "No that is not required") before I paid out any money.

I got the email yesterday that the CPT codes (Band and RNY) I sent her were not covered. But I should have my DR to send in a pre determination letter to verify. So now I don't know which way to turn either. I requested an insurance booklet from her today. I want to see where it say that. Is there a difference between "Not Covered vs Exclusion or Excluded" Because she definitely said unless it is medically necessary.

But then again, they told you that 3 times.

Dee66 · May 7, 2008

Well, here is the latest as of today! I have been in touch with the broker who handles my employers health ins. They are actually filing an appeal to make a one time exclusion for me on this surgery! I am so surprised but since I was informed one thing and then the other then they think they have a good shot. Also, since I have some medical problems as well it's not going to hurt my case. I will keep you all posted but please say some prayers and keep those fingers and toes crossed! Thanks