Question:
Anyone with Insurance Experience help with my exclusion
I have, like, NO hair left. I can't get a straight, or even consistent answer from UHC about an exclusion. Under Exclusions and Limitations, my policy description form states: Obesity-Health services and associated expenses for procedures intended primarily for the treatment of obesity (including morbid obesity). I am in contact with Walter Lindstrom and I'm putting together my first appeal. 1) Do I have a chance with this kind of wording?, 2) what should I include in my appeal to knock 'em dead (literally!) Thanks in advance!!!!! — SweetDragonfly (posted on July 21, 2003)
July 21, 2003
Sorry, Jill...I know this is not what you want to hear....
I had the same exclusion on my UHC policy. Walter Lindstrom told me that
he has never been successful with an appeal with this exclusion. He
refused the case.
Luckly (ha!), my company offers other insurance plan options (at a much
highter cost to me!). I had to wait until open enrollment and switch
plans. I'm getting closer...
— Tom Barton
July 21, 2003
I work in a doctors office that does RNY and I work in the insurance
department. Unfortunetly, any our patients that have UHC with that
exclusion, don't have many options. When it is an exclusion in your policy
it is something, typically, that the employer is aware of. Now, it is
possible that it wasn't addressed with your employer. Some options you can
try, if your employer is a "Self-Funded" policy, meaning they set
up the funds and tell the insurance company basicly how to
"spend"(for lack of a better term) the money. If this is your
type of policy, you can talk to your employer about seeing if they will
consider making an exception and allowing you to have this procedure.
However, as far as I know, most UHC policies are not self funded. Meaning,
you're paying for what you get. If this is the case, take it to your
employer. See if they are considering a new insurance, or if they would.
One that covers WLS. Here in our office, we have had several patients that
have UHC with that same exculsion. Do you have a secondary policy thru a
spouse? Sometimes even if the primary denies, the secondary might pick up.
Let me know if I can help you! Hope this helps! Good luck!
— Ashley S.
July 21, 2003
That is the standard UHC...NO. Sorry hun, hate to be the bearer of bad
news. :(
— RebeccaP
July 21, 2003
'However, as far as I know, most UHC policies are not self funded'---oooh
Ashley that is not true. The majority of them are.
— RebeccaP
July 21, 2003
I wish you well, and hope that your experience is better than mine. My UHC
policy went into effect after I had been approved by another company but
before the surgery date. We asked if it would be approved by UHC and the
business insurance agency said that all medically necessary surgeries would
be covered. When we received the written policy (about 30 days after it was
purchased) it was excluded. I appealed twice and then took it before the
State Insurance Commissioner - all without any benefit. I had diabetes,
high blood pressure, severe GERD, joint difficulties and the whole gamit of
obesity related co-morbids. It just did not matter. Our family decision was
that the surgery was necessary and so I had it on 3/17/03. United Health
Care is reaping the benefits as I am no longer on any of the expensive
medications. They will not cover my prescription vitamin. If I were you at
this point, I would see if I could upgrade the policy to remove the
exclusion; see if my employer would help pay for the surgery or obtain
private insurance coverage or even change jobs to get better coverage. I
was fortunate that I got in and out in 1 day at the hospital, but it still
cost over $20,000.00 for the procedure without any complications. I've seen
many go for $30-60,000.00 and I think that this is the normal charge. I'm
sure the insurer pays no where near this, but you will be billed for
"rack rate" if you are self-pay. I wish you much luck and
success.
— Rae J.
July 22, 2003
Hi there. Maybe try contacting the CEO's office either via telephone or by
mail. All phone complaints are responded to within 24 hours and they
follow up in writting within 2-5 business days. If you would like a
correct answer from someone who REALLY knows your plan, that would be the
route to go. When you contact the corporate office you will receive a call
back from someone who really knows your policy (usually in upper
management) in the office which services your policy.
UHC's Corporate Office can be reached at 1-800-845-2656 or via mail at:
UnitedHealth Group
9900 Bren Road East
Mail Route MN008-E116
Minnetonka, MN 55343
If you have any questions, feel free to email me.
— Kamy
July 22, 2003
You guys are all so wonderful! Thanks for all the great advice....I am
exploring my options and thanking God that I still have options. :0)
— SweetDragonfly
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