Question:
Can my employer be liable to pay for my surgery?

I was denied after completing the 6 month diet doctor requirement that Aetna has. After 3 months into fulfilling the requirement, unbeknownst to me, Aetna no longer covered the surgery. I was never informed by Aetna, or my employer. Aetna claims to have informed my employer, my second question would be...because my employer neglected to inform me of any changes, can they be liable to pay for my surgery?    — vividsunrise (posted on October 18, 2005)

October 18, 2005
Dawn, this sounds specific to your employer and I would imagine it would have been up to your employee to inform you of this. I was just approved by Aetna a week or so ago. I am so sorry this has happened to you. I would imagine if you had submitted your paperwork 3 months earlier you would have been approved. They should have notified their employees of the change in policy.
   — [Anonymous]

October 18, 2005
I would refer to your previous policy, some of them (mine included) noted that updates and changes may be made to the policy without notice and it is up to the member to stay current with coverages. I don't know if you have a similiar disclaimer in your insurance booklet or not. You can contact your HR department and see what they say, or if you are in a union contact them as well. I'm sorry this has happened. Best wishes.
   — Shayna T.

October 19, 2005
Hi Dawn, I am really sorry this has happened to you, but I hope that you can sit back and realize that the surgery is so much more important to you than to your hr people, and that they messed up--not to mess with you, but because your surgery wasn't at the forefront of their mind, as it is with you! So, although I am not a lawyer, you and I both know that your employer is not liable for your surgery. You are hurt and upset because this is another delay in the rest of your life! Believe me, I understand. When we finally make the decision to have our surgery, it's all we can think about, and when we get disappointed because of delays, we need for someone to pay!!! I waited for three months for a surgery date after meeting my surgeon and being told I was a candidate, then no one bothered to tell me that the surgeon stopped performing the surgery within a week or two of that first appointment! I had to wait until the medical group brought in another surgeon who accepted my insurance...etc. But you know what, Dawn, it all worked out in the end. I don't know about your faith and belief systems, but I hope you know that the plans we make aren't always what God has in mind for us and He always has a reason for stuff that happens, whether we like it or not!!! It will work out for you too, just not on your time, but His time. And it will work out better than expected. If you hold on to your pain and anger because the hr dept. didn't tell you about the insurance, the animosity is going to build and your workplace will become a miserable place to be. Let go and be more positive and proactive. It's October and most insurance companies have open enrollment this month--check to see if there's another company available. Who knows, you may even get better coverage, better doctors, lower co-pays, etc. Yes, there may be more delays, but what the heck, you've waited this long and now you're a little lighter! : ) I know when I finally gave up my anger and accepted the delays leading to my surgery, I became really appreciative because I later found out that the first surgeon (who only did distal rny) was battling malpractice suits and having problems with his own insurance. But my new surgeon was maticulous and thourough compared to the first surgeon, he only performed proximal, which is easier on the body, and I had more information than I ever expected, so I knew exactly what to expect. My point? I had great success, I'm healthier, and more informed than I ever thought possible, and it is because God was watching out for me on His time and not my own. You have a great support system here, and we're all pulling and praying for you--now get to work and get new insurance!
   — Patricia R.

October 19, 2005
Hi there! I just myself posted questions about AETNA? They are so confusing. All i can tell you is I have AETNA POS2, they accept it, however do I have to meet all their requirement? Did you have all the requirements? I have 9 monts Dr. diet, still do it. But did you have everyone of those requirements that your surgeon was even able to submit it? I had one center who wouldn't take my $, because they knew I wouldn't meet all the criteria. Now I went to this other Center who "GUARNTEED" me they could get it approved, so of course I was exstatic, and I hande them over all my $, to turn around and they now tell me they are not in my network, so out of pocket expenses are much higher? I just wanted to know what criteria you had submitted of AETNA's 8 mile long list. Thanks Liz [email protected]
   — lizbur129

October 19, 2005
My doctor's nurse told me that they were going to change, and that was why I made sure to have the surgery before they changed at the beginning of each year. I do believe that it is up to the patient to be proactive. I always call and talk to my insurance company before making any plans for medical care.
   — Novashannon

October 19, 2005
It should be open enrollment season for benefits coming up. You may want to check out some of the other insurance companies that are still covering the surgery.
   — the7thdean

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