Question:
my job is self-insured & they have an exclusion ,what next?
exclusion reads: "benefits will not be provided for weight reduction programs or treatment for obesity including any surgery for morbid obesity regardless of medical necessity". — stephanie L. (posted on July 18, 2001)
July 18, 2001
They are clearly excluding this surgery then. Now you should either change
insurance comapnies, or else find a way to self pay. How about home equity
loans? Selling a vehicle, your boat, etc? There are usually ways of
coming up with the money when we realize this is a life or death situation.
Best wishes.
— Cindy H.
July 18, 2001
Hi: If your company is truly self-insured, then you should know that they
are the ones that decide whether or not things will be covered. My company
is self insured, and we to had an exclusion for WLS. SO, I went to the
human recources dept and spoke with both the manager and the director. (I
knew them and got along well with the director) I went in loaded with
information along with what all my docs had said. It wasn't easy, but I
did get them to change their policy. So the start of this year it was an
included benefit, and I had my surgery on 2/2. So, it can be done. Don't
let them tell you it is out of their control, cause they are the insurance
and can decide what they will and will not do. If I wouldn't have gotton
it covered via the route I had taken, I was prepared to go higher up the
ladder. So, good luck to you!!
— Karen A.
July 18, 2001
Hi! My company is self insured and we have an exclusion also. I have been
in constant contact with my Human Resources department since I requested
approval from my insurance company. My HR rep said to get a denial from the
insurance first. Then they would look at taking a look at it. If you read
your plan carefully, you will see little things all over that you can grab
ahold of and run with it. For instance, it should say in your plan that the
plan sponsor can change their mind anytime they want, and just because they
do it for one person doesn't mean they have to do it for others. I'll send
you a copy of my appeal letter, for some ideas on what to look at. In it I
picked apart my entire plan (or most of it) and showed them all the reasons
why they could cover this surgery. It's a pretty aggressive letter, so I
don't actually think I would use it as a "first" letter to the
employer. But I would definately use it for a first letter to an insurance
company.
Kim
— K T.
July 18, 2001
OOOPS! I wasn't paying attention to who I was writing to - I think I've
already sent that letter to you haven't I?
Kim
— K T.
July 19, 2001
Your company does not have to change it's policy...all they have to do is
agree to go outside the current policy and pay according to the guidelines
they already have available. My company has done that for me and my
surgery is scheduled for 8/2/01. Make sure your surgeon writes it up as a
life or death situation and you should have no problems. Good luck!
— Sharon R.
July 22, 2001
I also had to fight a self insured company with an exclusion clause. Don't
give up!! Write letters to everyone including the HR director, CEO or
President of company, insurance company, state board of insurance, attorney
general, etc. It is your RIGHT to have the surgery. Use the American
Disabilities Act in your favor. Morbid Obesity is considered a disability
and it is against the law for any company to discriminate against you
because of your disability. Go and talk to an attorney who is not afraid
to take on insurance companies. I talked to 2 and they provided me tons of
free advice! Sue your company of you have to (often the threat will work).
You will WIN!
Virginia has now made it illegal to deny WLS. Stress the fact that it is
no different than diabetes or cancer. You have a medical problem NOT a
character flaw!
Need help? Email me at [email protected]
— barbara H.
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