Anyone has an employer that has an exclusion?

Ok here's whats up.  I first considered having gastric bypass surgery back in October.  Im going through Liv Lite.  ANyways they called my insurance company and was told "yeah no problem, heres' what you need to submit it"   So from there on,i got all my medical records from previous dr's, my psych eval and letter from my own dr.  It was all Finally submitted on January 12.  I was excited because i knew that was the first step.  A week goes by and the lady ive been working through at liv lite called and just had this voice that said she did not want to call.  Turns out theres' an exclusion with my insurance for wls for obesity.  I had them check would having the surgery because im type 1 diabetic or the fact that im morbid obesity ( a little play on words there) help.  None of it did.  I remember trying so hard not to cry all day and when i got home i just lost it.  I just completely broke down, because it was like all the research ive been doing and getting everything together was for nothing.  It literaly felt like someone took a knife and stabbed me in the chest.  Turns out the exclusion is not through the insurance but from the employer.  I was beyond floored.   But why oh why would they tell us yes, and why would i spend all that time and money to get everything together to be told no.  If i knew it was a no from the start i never would've even bothered.  Major complaints has been filed to the insurance company since they clearly have workers there that has lack of knowledge.  Whether anything is going to be done about it, who knows.   So now what do i do?  Do i fight my employer?  I love my job, i really do.  I dont want to do all this fighting to either be denied all over again, or do all this fighting to then be treated differently by my employer and have no choice but to either resign or quit.   I'm not paying almost 400.00 a month for insurance to have my employer tell us no because it's cheaper for them.   I'm sorry this is so long, but i need some advice somewhere.   Trish

Trish, i know how you feel my husbands employer has a big fat exclusion to! I to have done a lot of research and feel like it was for nothing, but i still am hoping maybe inc will change then maybe i will get some help to,Wish there was something i could say to make you feel better, just wanted to let you know there are a lot of us out here going through the same thing, i just dont get it , this is a life change for us and inc co just dont understand do they? I wish you lots of luck and hope someday you get the WLS to.

Hi Trish.  It sounds like your insurance is self funded by your employer, your employer is paying your medical claims and your health insurance is basically acting like an administrator over your health plan.   I ran into the same problem last spring.  So, I searched for another job and also one where if my new employer excluded surgery as well, I would make enough more in income to pay for the surgery myself.  I started looking and two months later, I found another job with a 20% pay increase and same kind of work.  And lo and behold, my new company's insurance does cover surgery, as long as I participate in a 6 month medically supervised diet.  I have one month left on the diet and I will submit my surgery request to the new insurance. Your employer should have a packet or booklet of what specifically they do or do not cover.  Your surgery exclusion is probably listed there. Good luck.

If your company is self insured, then you can speak with the benefits administrator at your company (many times, the human resources department) to let them know about your concern.  I have dealt with employees who have complained enough to their employers (who were self insured) about something not being covered to have the employer make an exception for them.  I think it is worth a try before considering choosing another company to employ you. I sincerely understand your frustration regarding the matter, but please consider that simply because you pay $400 monthly for your insurance does not mean that your employer has the obligation to allow every possible procedure to be covered.  When something is not covered under self-insured plans, it is usually due to attempting to save money and to cut costs.  If your employer did allow every procedure under the sun to be covered, then you would be paying a lot more than $400 per month.

 I KNOW JUST HOW YOU FEEL CAUSE I WENT THOUGHT THE SAME THING WITH BC/BS I WAS TOLD THAT IT WAS COVERD  THAT WAS IN 05 WAS SO EXCITED AND JUMPING AROUND AND THEN THE BIG BOOM SHELL HIT. THEY CALLED ME AND TOLD ME IT WAS NOT EVEN ON MY HUSBAND'S POLICEY IT WAS TAKEN OFF THE BEGINING OF THE YEAR. SO YOU KNOW I WAS PISSED OFF. SO ANY WAY I WAS TOLD THAT MEDICARE  WOULD PAY FOR IT. BUT THE HOSPITAL HAS TO BE A CENTER OF EXCELLANCE AND THEY ARE WAITING FOR THAT NOW. AND I STILL DON'T KNOW IF MEDICARE WILL PAY OR NOT STILL WAITNG  I WILL HAVE MY SLEEP STUDY DONE ON THE 28TH OF THIS MONTH. MY BMI IS 41 THERE ARE SOME REQUIRMENTS THAT THEY WANT YOU TO HAVE AND I DO HAVE  THEM  I'M A TYPE2 DIABETIC   HIGH BLOOD PREASURE ARTHIRITIS SEVERE.  SO NOW ALL I CAN DO NOW IT WAIT SO IS THERE ANY ONE ELSE GOING THOUGH  THIS PROBLEM?