Help: employer exclusion and health insurance approvals for surgery

[cap]

Is there anyone who's dealt with employer exclusions and health insurance approvals. My husband just got turned down for bariatric surgery because our health insurance policy doesn't cover it. We found this out a couple weeks ago. We were insuring ourselves with Blue Cross/Blue Shield Individual Policy (High Option) --- yes, we were paying out the wazoo for it ($1500/month). My husband had an aborted lap band procedure done 2 years ago (surgeon completely botched the job and my husband had a spleenectomy (spleen removed) and an esophogeal tear, and 2 hernias from it.

My employer had switched to United Health Care (UHC) and the policy looked good. So we asked for the information. Received it -- had nothing about any exclusions for bariatric surgery. To double check, my husband called UHC to verify that it would cover bariatric surgery since he knew that after he healed he would want to do it again. UHC said no problem that they would cover it.

So my husband heals up and we go in for round 2 of the surgery. Get all the medical clearances and submit the forms. We were rejected because the employer didn't choose to elect coverage for bariatric surgery. It is medically necessary for my husband: he has a number of comorbidities. His Blood Pressure medicine is maxed out. He has high chloresteral (out of control). He is diabetic. He has acute kidney disease (stage 2 -- 30-40% kidney function). He has sleep apnea. So we have a large stack of letters from his doctors (some of whom are leading figures in the field. His hospital is a "Center of Excellence" in Bariatric Surgery, etc) stating that this procedure is medically necessary. He is set to have a cardiac catheterization in 3-4 months if he doesn't have this surgery. He will be on dialysis within 5 years according to his cardiologist. His pulmonary doctor has called him a "walking time bomb".

I am going to write a letter to HR but I highly doubt that they will change the policy even though it is cost effective for them. The hernias still have to be repaired so he will be "opened up" anyhow. I have called Massachussets (where the company is Headquartered) state insurance department to initiate a complaint and the Pennsylvania (where I live) state insurance department. The Massachussets office said that the employer exclusion is rarely overturned. I am hoping to find the materials that was sent to me at the time of selection so I can send it to the State Attorney General and complain about sales misrepresentation. No one moves from a gold plated insurance like BC/BS High Option to a plan that doesn't cover their conditions.

The state insurance department said to continue the appeal and that they would step in afterwards for a review. But they said that it really doesn't tend to change things in my favor.

I am wondering what the right thing to do is. Continue the appeal process or start looking for another job (in this economy) or another group health plan. Does anyone have any good ideas for a group health plan from an association? My husband is in IT and I am in management consulting. He is a contractor so his company's health insurance policy is lousy. We looked at freelance groups but they are New York City centered -- they only cover stuff in NYC. It's an option but it's a haul. Is there anything that covers people in PA. Chamber of Commerce?

[sarcasmo]

1. Look for another plan. My wife had the surgery five years ago and has lost 120 pounds

is no longer diabetic and much healthier.

[dflprincess]

2. Call your state attorney general's office as well as the insurance department

From what you said about NYC, I'm assuming you are in New York State and UHG has had serveral run ins with the state or New York(back when Spitzer was AG - it was one of the reasons I liked him) none of which ended happily for UHG.

Also, if you can find a way (and don't mind doing it), go public. Several years ago in Minnesota a breast cancer patient and her lawyer managed to shame her insurance company into paying for reconstruction on her remaining breast. She had had a mastectomy and the insurance company would pay to reconstruct the missing breast, but they wouldn't pay to even it things out. So this woman was going to wind up with a "perky" breast and a 50 something breast - totally asymetrical and, as a 50-something woman I say totally unacceptable. The other major insurance companies in the state would pay for this kind of surgery and, after all the bad press they got, so did hers.

This is just another example of why we need a system that will allow doctors to make treatment decisions.

[yellowdogintexas]

3. The plan isn't going to cover a brand new lapband. However your husband's

situation is that of surgery necessary to correct complications of a prior procedure. If they can't get you on pre existing (which they can only do if you were without any kind of coverage for over 60 days) you may be able to get it on the medical necessity documentation.

Your physician needs to prepare a well documented case for you, that focuses on the complications part, but also addresses the numerous other health issues that the procedure will relieve.

Good luck, I have been a claims processor, and I know exclusions/limitations are hard to get around because they are normally very cut and dried and specific (except of course for the generic 'and other conditions deemed not to be medically necessary). Your employer should have sent out a more specific copy of the plan, or UHC should have sent it to you.

[cap]

4. he doesn't want a new lapband,

he is going to have a Duodendal Switch -- more drastic where the intestine is hooked directly to the esophagus.

We've kept continuous coverage so pre-existing conditions clausewont apply. It is medically necessary. We have reams of documentation and letters an inch thick to verify this. I am sending it in tomorrow.

What to do about the employer exclusions? They weren't in the original documentation. Who is at fault and can they be forced to do the medically necessary surgery? We asked about this explicitly up front.