Ok here's the story! I have united healthcare choice plus, however employer has added wls exclusion! Employer has agreed to try to take out exclusion but when called to add the insurance comp said that they could just submit my pre determination letter and overide the exclusion in my case! However they never said what was required of me! So I don't have policy to look at and get requirements or anything! Doc office is slow and acting like they don't know what to do either! Has anybody ever had an overide on exclusion or heard of such? If so what do you suggest me doing to get the ball rolling?

Amy:

You and I have the same health insurance and the same exclusion.  Your situation gives me hope in mine.  I read your profile and see you have already had wls and seeking a revision.  That being said I am seeking RNY and it is medically necessary.  As far as not having the policy on hand you can get a copy from your employer or UHC.   Basically what I have found out is UHC really requires is a 5 yr history of being obese. Again going on my dealings with them and my policy.  

I would begin by calling UHC and seeing what the next step is.


I am very interested in the out come of your situation.

Please keep us abreast and good luck on getting what you need.


Oh I thought of one question that I have.

Is your UHC policy goverened by the California Department of Insurance?



hugs and well wishes from Baltimore

Zells_lori is "abuddingrose"

Whatever you do never give up! Now when I call of course all they say is excluded and that's all! They told my employer what I needed to do but never said what the requirements are! All they said was have surgeon send pre determination letter! So I wanted to know what I needed 4 that! Now I don't know where its governed but I have my insurance in Wisconsin! I don't if policies vary from state to state or not! I'm new to insurance game! But I will keep you posted on the outcome! Good luck to you on your venture to a new you! Talk to your employer about the exclusion! All they can say is no! Its worth a try!

amy:

Thanks for rresponding.  If you have a copy of your Certificate of Coverage it states on the first or second page where it is regulated.

My insurance is regulated by California Department of Insurance and I live in Maryland.
Also maryland has a state law that requires group health insurance to cover wls if a certain criteria is met.  I have a listing of case law that supports the concept that the laws of the state where the insured lives can not be negated ie ignored. 

I am saving that for anther appeal.  

I would call UHC and tell them what your employer was told and insist to talk to someone to find out what is needed for the predetermination  letter so you can get what you need.  Don't forget to document every phone call, who you talked to , thier posisiton and the time and date.

I will also keep you posted from my end.


Good luck in your journey and please add me to your friends list.

BTW I Never GIVE UP lol


Hugs from Baltimore
 
Zells_lori is "abuddingrose"

I also have United Healthcare Choice Plus. I live in Maryland; the policy is written in Virginia. My employer specifically excluded WLS coverage from the policy.

Lori - were you successful in getting a waiver to the exclusion? 

And - would any complications be covered by UHC after WLS?

Thanks!

Sheri

Sherri:

Not as of yet how every I did find this little tid bit that you may want to check out . I have included the link for you check out and check to see if your policy is governed by the state of virginia and what the requirements are that make it necessary for insurance companies to cover wls.
Hope this helps you some

In the last six years, at least ten states have established task forces or commissions to study obesity: Florida, Illinois, Louisiana, Maine, Maryland, Mississippi, Nevada, New York, Rhode Island, and Tennessee. The National Institutes of Health (NIH) formed the NIH Obesity Research Task Force in April 2003 to accelerate national progress in obesity research.

Four states (Georgia, Indiana, Maryland, and Virginia) have legislation regarding insurance coverage of obesity treatment. In Georgia, health care policies may offer coverage for the treatment of morbid obesity. In Indiana, HMOs and insurers must offer coverage for non-experimental surgical treatment of morbid obesity that has lasted at least five years and for which non-surgical, physician-supervised treatment has been unsuccessful for at least 18 consecutive months. Maryland law requires insurers, HMOs, and managed care organizations to cover NIH-recognized surgical treatment of morbid obesity. In Virginia, insurers and HMOs must offer coverage that is the same as that provided for other medical and surgical procedures for NIH-recognized treatments for morbid obesity.



http://www.cga.ct.gov/2005/rpt/2005-R-0160.htm

Hmmm.... I see a problem - UHC OFFERS the coverage - but my company elected not to add it to the policy.

Wish I was a lawyer!!

:)

Thanks, Lori!

Sheri

Hi All,

I too have the UHC Choice plus plan in Georgia. We do have a law on the books but that does not guaranty coverage. I wrote a letter to the State House of Representatives and Senate Insurance Committee and Health and Human Services committee about the issue with the word "may" in Georgia's law. I copied the State Insurance Commissioner and have been dealing with them for a couple weeks now. Here is what I have learned.

1. There are 2 types of insurance plans and each type is governed by different laws and government agencies.
        Self-Insured plans - are plans where the company pays all of the medical expenses and can override any decision. The insurance company on the card for these plans is just the paper pusher or administrator of the plan for the company that you work for who is paying the bill. Self insured plans are not governed by or covered by State or Local laws as they fall under a federal law written in 1974 (I believe) and they are governed by the Department of Labor.
*Most Large companies are self insured. 
       Fully Insured plans - are plans where the company pays a monthly premium to the insurance company to insure their employees. The Insurance company writes the policy and governs it. The company has no say in what will be approved on appeal. The company has to purchase a separate rider for WLS for the plan that we have as it is a fully insured plan. Fully insured plans are governed by the state insurance commissioner and state and local laws apply to them. Most small companies (200 or fewer employees are fully insured)

Here is the dozy, UHC is claiming with the insurance commissioner that our plan is self insured. My HR representative has told both me and the insurance commissioner that it is a Fully Insured plan. I am waiting to hear back from the insurance commissioners office on how to proceed, but I have written an appeal letter and have it on standby. If UHC continues to state that it is a self insured plan, I am going to ask my HR rep to write a letter stating that the company approves of me having the surgery and include that in my appeal.

We can win this fight! We just have to arm ourselves with all the knowledge we can!
I am still waiting to see what comes from all my state representatives about my request to amend the word may to SHALL!