Question:
Employee Exclusion at United Healthcare, How can this be?

I've been denied for Vertical Banded Gastroplasty by United Healthcare because I am an emloyee of this company. They said the exclusion is for employees only. I've sent my first letter of appeal in, but need to know, can they exclude this procedure because we are employees??? Please help me if you can. thanks, Tina W. from Minnesota.    — Antoinette W. (posted on January 18, 2003)

January 18, 2003
Tina, just because an insurance company covers WLS for some, doesn't mean that it will cover all. You probably know that employers pay for plans and are able to pick and choose in some areas what the plan they buy will cover. It sounds like your division of United Health Care has CHOSEN to exlude treatment for morbid obesity. In many cases (that I've seen) an exclusion is a dead lock, not able to be swayed by appeal. I know of people who have hired Walter Lindstrom at Obesitylaw.com to try and fight exclusions with limited or no success. A company, no matter what kind of service they provide can choose to administer their health plan as they see fit.. unfortunately denying the right to this life saving surgery isn't a crime, though I believe it should be. ~Peace
   — Joscelin

January 18, 2003
Tina, There are a couple of things to consider. First, find out if your employer is self-insured or not. This means that they actually pay the medical claims at a discounted rate, because United Healthcare manages them. If they are not self-insured, all they pay is a monthly premium and the insurance company pays the actual claims. The insurance company can and will exclude everything they can to keep costs down. IF they are self-insured, then the employer has the right to override any decision made my the insurance company. This doesn't mean they will, but they can. If they are NOT self-insured, and you have been denied due to an exclusion, most of them are air-tight. My advice is to fight, fight, fight. Keep sending in appeals and document everything. Also, write letters to your congressmen and senators, and also to your state's insurance commissioner. It's the only way the laws will be changed to MAKE insurance companies pay for this life-saving surgery. Best of luck to you. Ginger
   — Ginger N.