Employer Excluded WLS Rider on Anthem Policy

vamaid · July 11, 2005

I have just been informed (by surgeon's ofc) my employer specifically excluded the weight loss surgery rider on on their group plan. She suggested perhaps the employer would add it to their plan if they knew an employee wanted it. My guess is the employer excluded it because they didn't want employees having WLS on their dime. To make matters worse, I'm not an employee there anymore - I am paying my health insurance premiums via COBRA. In any case, is anyone aware of someone having a successful appeal (due to BMI, co-mobities, medical necessity) when the group's policy did not include WLS? Thanks.

Alexandra · July 11, 2005

No, I'm sorry to say. But if you're no longer working there, perhaps a new job with a different policy will be better for you? When there's an exclusion (in states that allow it) it's VERY hard to fight.

j_war06 · July 11, 2005

Hi, I just sent in my appeal letter last Thursday after collecting evidence for 2 MONTHS! It was a long and horrible process, but I did get some very useful information to use against them. First, I looked up my policy online on their website, then I made notes of what they would and would not cover concerning any co-morbidities. After that I added up all the expenses that they have spent on me the past 3 years, then did some estimated math from facts that I received from my doctors treating my comorbid conditions to project how much they would spend on my co-morbid conditions by the year 2010 (when they will no longer be carrying me.) For my last straw I put in some personal emotional trouble, like I have not went to school in about 4-5 months because of my co-morbid conditions, but I also threw in some legal "mumbo-jumbo" because I am a concurrent law student and could get that information from a special website for lawyers and law students and this is what I found. "Under the American Disability Act Obesity and Morbid Obesity is a disease and a disability." This means that since I am fat (morbidly obese) that they are not supposed to be able to any longer discriminate against obese people within the workplace, or any other function open to the general public, just like they can not not hire someone because they are missing an arm or a finger, or are in a wheelchair. This also means that the insurance should actually cover you if you have an actual medical problem because of the obesity (like I have chronic and severe knee pain, depression, chronic fatigue syndrom, TMJ, etc...) if these problems did not exist before you were a member on that plan, they had to develop while you were covered by them.

SEC. 12112. [section 102]

(a) General rule. - No covered entity shall discriminate against a qualified individual with a disability because of the disability of such individual in regard to job application procedures, the hiring, advancement, or discharge of employees, employee compensation, job training, and other terms, conditions, and privileges of employment

an insurer, hospital or medical service company, health maintenance organization, or any agent, or entity that administers benefit plans, or similar organizations from underwriting risks, classifying risks, or administering such risks that are based on or not inconsistent with State law; or

Alexandra · July 11, 2005

Wow, Jodie, sounds like you went at them with both barrels!! My fingers are crossed for a great outcome. Please keep us posted!!

j_war06 · July 12, 2005

Thanks Alexandra, but nowmy mission is to help everyone I can get accepted, including myself. All in all I had to go after them I am scared to death that they will not accept the surgery, but it also made me angry that an exclusion like that could exist, so I did some research, and now, even if I have to pay for my surgery, I want to help other ppl try to get accepted by their insurance and I have also become an Obesity Epidemic Activist to support American Weight Loss through whatever means fits the individual, so if anyone else wants some information just message me.

Sandy3 · October 7, 2005

Jodi:

I have been reviewing older posts as I am planning on pursueiing appeals up to and including usiiing obesitylaw.com. Your post was very helpful. Where are you in the process.

Thanks

Sandy

j_war06 · October 9, 2005

Sandy, I had surgery on August 26, and the insurance refused to pay and the company refused to change their exclusion. I am going to continue to fight them to pay, but all in all we ended up taking out a loan from the bank and its not too bad, its just not morally right that the world makes fun of me for being fat and feels sorry for me and even offers to help, until it comes down to actually helping, then they say, "I'm sorry we dont cover that."

Sandy3 · October 9, 2005

Thanks for responding Jodie. I see that you are 17. That made my heart sing. I know you must have expierenced a lot of pain in your life already because of being overweight. But thank God you now have the best (not perfect) tool to date so that it may save you a lifetime of suffering. Did you get banded? I read somewhere that they are doing a study. They are banding people who are simply obese in the hope that this will save them from becoming morbidly obese. The article said that this may be the wave of the furture. Some people have been getting this surgery on an outpatient basis. Wouldn't it be great if the price came down so that more people could afford it.

Good for you Jodie. You are an inspiration to me. Keep fighting. I have read that some people are trying to get insurance to reimburse them. Please tell me more about becoming an Obesity Epedemic Activitist. I am ready to fight!

Sandy