Question:
Customer Serv. Rep told me they would cover WLS if it were proven medically necessary

and since I was going out of network with a referral they would cover 90% instead of 70%. My surgeons office told me they were told that benefits for WLS were available under my plan if it was medically necessary. Today I received a letter from insurance that said it is excluded from coverage under my contract. Since we just became covered under this plan I have nothing in writing. Can they do this? They lied to me and the doctors office. I have no proof though. I wish I had recorded the conversation. I plan to appeal. If anyone has any suggestions or knows of any laws about this let me know. The insurance is Atrium- a MN BC/BS plan, I live in ND. Thankfully I kept Aetna, choosing to pay two premiums as they had approved me in July but I chose a new surgeon and they required him to submit a new request. I'm still waiting to hear back on that. Aetna only pays 70% of a set amount so I hope to get approval from both companies. Thanks, JB    — Julie B. (posted on October 3, 2000)

October 3, 2000
The exact same thing happened to me. I had even went as far as getting materials that they said they would need to be able to give me the precert. I spent money and a lot of time gathering this. Then, they sent me an email with an "oops, sorry NOT covered, regardless of medical neces. period, end of discussion." Needless to say, I am mad. I am currently working with the Human Recource Dept at work (Mine is a PPO self insured plan) I have a meeting with them next Monday. However, I did keep copies of all the email correcspondence I made with them. I would suggest you might talk with your HR dept. It is them that decides what is/is not covered in thier particular plan. Who knows... maybe they will be able to help. (that is what I am hoping)
   — [Anonymous]