Question:
Are any other Texas state employees being denied by Scott and White?
I was all set for surgery. I had just completed my psych exam and six months of the required weight loss program. When I called the nurse to make my scheduling appointment with Dr. Symmonds, I was told that Scott and White was no longer paying for state employees to have the surgery. I am heartbroken! Of course I am appealing. — beckyvee (posted on May 13, 2003)
May 12, 2003
See question 51 or so below. Another person has apparently had the same
problem. I wuouldn't think that a employer could change coverage
mid-stream. The employee can't change coverage except during open
enrollment so how can the employer change? This should have been
contracted between the state and the insurance company.
Good Luck.
— Carolyn M.
May 12, 2003
Carolyn, most insurance plans have a statement somewhere that they can make
any changes to the plan at any time without having to notify anyone. As an
example, our plan changed to include people with a BMI between 35 and 40
with co-morbid conditions in April, and open enrollment is in October.
— koogy
May 12, 2003
BECKY! Thank heavens I see something from another one of us screwed State
of Texas Employees. I work in Austin, and was in the Bariatric Program with
Scott & White, as well. Called last Monday to leave a message with
Radiant to ask if the appointment with Endocrinology would actually be held
on the 26th (Memorial Day). Got a sad-sounding message from her at work
the next morning saying that, as of May 1,2003, the state had dropped the
part of the package that included the Bariatric Surgery. I thought that
surely I'd have some ground for making the claim of treatment "already
in progress," thought maybe there was a shot at allowing at least
those of us already in the program prior to May 1 2003 to continue. Now,
are you ready for this further blow?
I called the ERS (Employees Retirement System) and spoke with a
Representative there who told me that "Scott & White should have
never even been talking to people about he surgery," that it
"NEVER was a covered benefit!!"
I told him that that wasn't possible, that I'd been in the program for 7
months now, had attended the meetings and seminars, had had the lab draws,
was had taken time off work, had put wear and tear on my car driving back
and forth to Temple, was mid-way through the Endocrinology part, etc.
He continued to say that Scott & White had been the party in the wrong.
I asked who'd been paying for my previous 7 months in the program, who'd
been paying for the surgeries already performed? The State of Texas was
bound to know this treatment and surgeries were going on, why weren't any
of the State Employees notified, if we were in a program that wasn't
covered???
He said that "maybe" the state should have sent us all something,
but that didn't change the fact that it won't be covered.
Becky, we've all got to do something. I've sent a written complaint to the
Medical Director of Scott & White (Dr.James Rohack), and spoken by
phone with 4 different attorneys, all of which say, "I'm not your man,
but here's the name of someone who is." So far, the next referred
attorney has said the same thing. I'm waiting on a response from one last
one now.
Unfortunately, privacy laws prevent anyone from hooking us all up, and
figuring out what we can do. The best we can probably do (if that) is to
force them to allow those of us in the program prior to May 1 2003, to
continue in the program. The contract the State ammended with Scott &
White, effective May 1, totally sealed out the possibility of having the
surgery covered.
Please Becky, contact me (I'm on this site). I'd been denied numerous
times with prior insurance carriers, and other routes I tried to take. I
only changed to Scott & White BASED ON WHAT I THOUGHT WAS THE CHANCE TO
HAVE THIS SURGERY, and neither my Benefits Coordinator, the representatives
with Scott & White, or anyone else told me any differently prior to my
changing over. If you find out any recourse we have, please post it on
this site. I'm devastated over this, which, unfortunately, reverberates
onto my family, who prayed with me to have the opportunity for this
surgery, as well. Let's all, as employees of the State of Texas fight this
with everything we can muster.
— pam C.
May 13, 2003
Becky, and anyone else who has ideas for Texas State Employees being denied
by Scott & White. I'm in the profiles on this site, but my e-mail
address has changed. How do I get it updated - tried the "updating
you file" route, wouldn't work. Anyway, it's now
[email protected]
— pam C.
May 13, 2003
Susan,
I can understand an insurance company changing the requirements for surgery
(of any type) during a contracted period. I just still don't understand
how they can completely change the contract itself (eliminating coverage
completely)for this very reason. People make decisions on their insurance
coverage based on what the plan is supposed to provide over the next year.
Over the past 20 years I've had a variety of different insurances including
Aetna. None of them, including Aetna have ever made a change in coverage.
Aetna changed their requirements mid-stream (as many insurance companies
do), but they did not change the coverage.
I know this wasn't your question, but since you directed your reply to me,
I just wanted to clarify my position on this.
— Carolyn M.
May 13, 2003
Pam:
Our stories are almost identical! Like you, I only switched to Scott and
White so that I could get this surgery. I checked this out thoroughly and
was assured that all would be okay. My husband says that we should band
together with other denied state employees. Anyway, call me. I sent you my
phone number in a private email. Hang in there! There is power in
numbers!!
Becky
— beckyvee
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