Question:
The company I work for is Self Insured.
means that they (meaning my bosses) can say yes or no as far as approval is concerned? I saw something about it in the chat room and didn't catch the details. — Jenny C. (posted on October 7, 2001)
October 7, 2001
Self funded policies do not mean your boss decides whether you get to have
this surgery. It means that the owners or super big wigs created the
contract and they have a big bank account in which the claims are paid out
of. Usually some other insurace company manages the claims payment. And
your employer mails them a big check once a month to cover the cost of the
claims and the cost for the other company to "take care of it".
— RebeccaP
October 7, 2001
My company is also self insured. They have several plans to choose from
and each of the plans "administrate" the claims based on a
contract they have with my company. While they administrate based on a set
of agreed upon set of policies, those policies can be challenged through
your human resource department. The bad news is that you usually have to
go through all the medical company's appeal processes before you can appeal
to your employer to overturn the decision if you are ultimately denied.
For example, my insurance carrier had a blanket exclusion for any
treatment, including surgery for weight loss or morbid obesity, no matter
what your co-morbidities were. I was in the process of my final appeal
when I opted to change companies during open enrollment period. I had
researched and the medical company I now go thru,Aetna, covered the
surgery. If I hadn't changed I could have gone thru the final appeal with
Keystone Health Care Central and if still denied, then I could have
appealed to my human resources deparment to review my case and choose to
cover the surgery. I hope this all makes sense. If it isn't clear, feel
free to email me with any questions.
— cheryl R.
October 7, 2001
I had sooooo much trouble w/self insurance, I changed jobs, by the time I
would have had a hearing and paid $10,000 out of pocket, it would have been
2003!!! Good Luck to you!
— Cindee A.
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