UHC KNOWLEDGE

does anyone here have expert experience dealing with uhc group insurance and california laws that apply to contracts written here but implemented in other states?

It probably would be helpful if we knew your specific concerns.

There are at least two people that I can think of that might be able to help you.  Diana Cox being one and Vicky on the Lap Band or Main Boards being the other. 

By no stretch of the imagination am I an expert, I'm just lucky enough to have very good insurance that, thus far, as covered everything I could have reasonably requested from it.  But my portion of the policy costs a lot.

Lisa

I will try to be as brief as possible.  I have United health Care  Choice Plus and the policy is written in and governed by law in California.  Any treatment for obesity is listed as an exclusion ( including medical necessity)and I live in Maryland.  I an trying to find out if there is a way they are required to cover the surgery.

I have contacted my benefits rep and asked for a rider.  She told me that it could not be done on an individual basis it would have to be done for the entire company.  She is checking on it for me.   I just want to know excactly what my chances are of really being able to get this paid for.

With out it I am sentenced to a life of pain, limited mobility and many additional co morbidities
possible early death and I do not want die young like my mother did. ( her age at death 57 and my current age is 51)  I am need of a total knee replacement and my ortho does not want to do it becuase of my weight.  He feels if the weight comes down i may be able to delay the tkr for maybe 10 yrs.  If it is done now there is a good chance of having a lot of revisions or even possible amputation if the shin bones shatters or my thigh bone becomes dislocated.

I actually work for UHC in the Appeals Department and I
can tell you that the benefits differ from state to state and
California laws are very different from all other states. Have
you been denied surgery and have you appealed the denial?

Katie

katie:

Thanks for the response.  No I have not been denied as of yet.
I live/work  in the state of Maryland.  UHC is my group health insurance and the policy is written in and governed by the state of California.  My employer has any treatment for obesity as an exclusion.  The health insurnace is not self funded by my company and they have employees all over the world.  My paper work has not even been submitted yet for the surgery and won't be until i fininsh all of the preliminaries.  which will happen by June 1.

I know that they require a 5 yr history of obesity, BMI of at least 40 or 35 with co morbidities of which i do have . ( hi blood pressure, anxiety, hi cholestoral, and sever osteoarthritis in my knees to the point that I saw an ortho about a total knee replacement.  He does not want to it at this point due to my weight.   I currently can walk or stand for very long ( like 15 minutes max) driving. housework, intimacy and social events are difficult because either I can't keep up or I am in so much pain that I have to set on the side lines. 
Below is a section of the law for the state of Maryland and  I have been looking for a definition or interpretation of the  phrase below in bold type.  (lines 24, 25, 26, and 27.  Any comments  advice that would be of helpful is greatly appreciated. 

Lori
Article - Insurance

15 15-835.

16 (A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS

17 INDICATED.

18 (2) "BODY MASS INDEX" MEANS A PRACTICAL MARKER THAT IS USED TO

19 ASSESS THE DEGREE OF OBESITY AND IS CALCULATED BY DIVIDING THE WEIGHT IN

20 KILOGRAMS BY THE HEIGHT IN METERS SQUARED.

21 (3) "MORBID OBESITY" MEANS A BODY MASS INDEX GREATER THAN 40

22 KILOGRAMS PER METER SQUARED.

23 (B) THIS SECTION APPLIES TO:

24 (1) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT PROVIDE

25 HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS ON AN

26 EXPENSE-INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS

27 THAT ARE ISSUED OR DELIVERED IN THE STATE; AND

28 (2) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE HOSPITAL,

29 MEDICAL, OR SURGICAL BENEFITS TO INDIVIDUALS OR GROUPS UNDER CONTRACTS

30 THAT ARE ISSUED OR DELIVERED IN THE STATE.

31 (C) AN ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE COVERAGE FOR

32 THE EXPENSES INCURRED BY A PATIENT WITH MORBID OBESITY FOR ESTABLISHED

33 SURGICAL TREATMENT IF:

34 (1) A PHYSICIAN DETERMINES THAT SURGICAL TREATMENT

 

12 SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF

13 MARYLAND, That the Laws of Maryland read as follows:

14

Katie:
I have found that my insurnace is governed by the state of California.  I have appealed to my employer to lift the exclusion through a rider, and explained my medical need and how having this surgery covered would benefit others that work here.
She is looking into it.  But I have one question for you....
Have you ever seen an apeal to exclusion overturned and approved due to medical necessity?  and if so what is the process?