Backstory: My insurance nightmare and happy ending story
Jul 18, 2013
I realize there is a gap in my blogs that covers this period of time, so I'm putting it here for reference.
My first submission went into UHC in December 2012. My BMI was 38.3 and my height, as I later found, varied by 1.5 self reported inches in the 6 years represented in my medical chart. My UHC plan required a BMI of 40 and 5 years documentation of MO by an MD. Don't worry, the insurance coordinator in my doctor's office told me, they'll take 35 with comorbidities. No, they didn't. I was denied in late December.
The doc's office clarified my height based on medical records, and resubmitted to the next level appeal. By then, we had missed the window for peer to peer. This was in mid January. I was denied again, this time by a UHC plastic surgeon, still because I was underfat/overtall. At this point the insurance coordinator said there was nothing else she could do for me. That day, I hired Walter Lindstrom's office.
The next appeal was to my husband's employer. It was due in late March. Lindstrom's office put together a 60 page document explaining how UHC's guidelines were outdated and how I should really qualify, and added another 60 pages of my medical record. At the top of the pile was an official statement of height and weight from my PCP. These latest values put me over the threshold of 40. We expected roughly 30 days to hear a reply....nothing.
Kelley Lindstrom started calling the employer to see if she could get a status update. The person we sent the packet to, as dictated in the second level denial letter, no longer worked there. Since it was my husband's employer, he scoured his Outlook directory for HR contacts. Kelley used this to find one who could confirm it had been submitted to the right place but could not find it. We had to resend, but we weren't penalized because we had a delivery receipt prior to the due date. By this point, it was late April.
This contact then was able to get us on the docket for the internal review board for early May. Kelley worked with her to get her to really understand what was going on, why their criteria was outdated, the key points she should address, etc. We were not allowed to present on my behalf. This contact was going to handle everything on my behalf in this meeting.
Kelley called me the night before and said she felt we had a 75% chance of things going well. It was my Hail Mary pass. My last chance. If I was denied, I had no recourse or options for external review because of the way the insurance plan was structured. My next option was going to have to be to keep the weight on, and restart the submission process after 6 months from the original submission date. The only hopeful thought I had at that point was that because my weight had ballooned, I would certainly qualify based on the stated criteria.
I expected not to hear anything for the remainder of the week, but Kelley called me the day after the review board met to tell me I had won. Even more importantly, the company's medical director realized, as a result of the thoroughness of the argument that Lindstrom's had put together, that their criteria was outdated and that they were telling UHC to change it. So, not only had I won my battle, but I had made it easier for others who followed to get their surgery, as well. I was elated.
An important thing to note, here. I didn't win automatically because I now qualified based on my confirmation of height and weight, but the height certification was important. Typically, they won't allow NEW medical information to be added (e.g. my weight continued to climb), but height apparently was assumed to be static, something that doesn't change. So, the committee considered my height as confirmed by my PCP. That value superseded all of the other height readings in my chart.
My surgery was June 12. I probably could have had it earlier, but decided to hold off a couple of weeks in order to finish a project at work.
I feel for anyone caught in denial hell. The first 6 months of 2013 were awful for me. I had had to reject a number of dreams (I will be looking much better for swimsuit season, I will be close to normal by the 2013 work holiday party, etc etc etc.). I was not able to lose weight, not knowing what was going to happen next. I was in limbo mentally and physically. I was miserable. It was awful.
My advice: fight the fight if you're denied, no matter the reason. Get an advocate (I really recommend Walter Lindstrom) if you can't fight it yourself. Don't give up, but pity parties are ok, and probably necessary. And, talk to someone who's been there. A friend...hell, me! Message me if you need to. I understand. It is a sucky reality but it is winnable. Hang in there, and most importantly, be strong.
Related post: Tips for newbies worried about qualifying for their insurance: http://www.obesityhelp.com/forums/insurance/4634683/Tips-for-newbies-who-are-worried-about-qualifying-for/