Self-Insured Employer in MN ?!?!?

stephybottom
on 6/6/07 11:14 am - New Richmond, WI

The company I work for is self insured. They use BAS (Benifit Admin. Systems) and Preferred One (PPO). I do not completely understand the relationship between these two enities. They are both listed on my insurance card. Our "Plan" states in the exclusions portion, "Any surgery..... relating to obesity or primarily for weight loss...whether or not recommended by a Dr... or any complications thereof." will be excluded.  BUT: Preferred One has the typical guidlines required for surgergy (BMI over 40, comorbidities, over 18, BMI over 34 for 3 yrs......etc.)  To me, it looks like P.O. and BAS contradict each other. Is this wording considered "iron clad" or are they just saying it needs to be med. needed???? Do I have a chance? I'm still really early in the planning stages of getting surgery, but I'd like some input. My HR person at work couldn't give me a definate answer and I'm afraid that if I call my insurance co. they will hurry up and MAKE IT iron clad. Thank-you in advance to any advice!!! 

(deactivated member)
on 6/7/07 7:38 am - TX
My company also self-insures. What happens in these situations is that your employer pays for the medical and uses an insurance company to take care of the medical approvals etc. Your company choses its own plan and exclusions because in the end, they are paying for it. My company has a doctor that writes our policies and then the policy is handled by humana, contact HR again and again until you get an answer. Also, do not be afraid to call the insurance company, they would have knowledge as well. Your employer already has a contract for medical- it may be for one year or more and may even be about to change. I have learned that you are your own best patient advocate!
stephybottom
on 6/7/07 8:23 am - New Richmond, WI

Our policy changes on a yearly basis, end of year actually. I am hoping to get this done by the end of the year before they have a chance to make the exclusion iron clad. Right now I have my two HR people making calls to feel things out so I have an idea of what I'm up against.

I've noticed that there are a lot of people who've been aproved through Preferred One but I guess I don't know how many of those had to go though 3rd party administrators..... Every time I find one piece of evidence in my favor, I find two more against me.   (((((sigh)))))

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