Relationships between PPOs & employer?
What is the relationship between PPOs and
employers? I thought this process was going very well for
me. I sent in my letter and the woman at the
insurance company said everything looked good it just had
to go infront of a review board. When she called to
tell me I was denied. I asked to see the policies on
denial and she said the policy wasn’t available. And
that there was an exception in my husband’s employer’s
policy and i had to take it up with them. SO my question
is who do I fight here? The insurance company or the
employer? I feel like an exclusion is discrimination. It is
directed only to the obese. Also, the clause is for weight
loss treatments and medications, but they had no
problems paying for 2 different weight loss meds that
failed.<br>Anyway, I am at a loss–unsure of what to do next…
December 2nd, 2003 at 9:19 pm
I encountered the same thing. I immediately
called my husbands employer and had them send me the
most recent benefits handbook, and looked up the
information myself….I then called the insurance company and
gave them the information over the phone, and also
faxed the page that said "no weight loss treatments are
covered UNLESS used for the treatment of MORBID OBESITY"
That was all the ins. people needed to see….they
then required that I have a psych evaluation. All in
all, my approval was pretty quick….initial
consultation on jan.18,2000. approval…wed.feb.9th. surgery
mon.feb 21.<br>that was 8weeks, and 50 pounds ago!!(yeah)
The gal at the insurance company said if I wouldn’t
have stayed on them, I still wouldn’t be approved at
Christmas!! I guess I am saying, know your coverage, and
stick to your guns! You will be forever grateful you
did!! Best of luck to you! Kelli
December 3rd, 2003 at 1:44 am
I would direct my attention to the Insurance
company… ask them AGAIN for their WRITTEN policy
guidelines.. ask to speak to a supervisor only… when writing
to their medical care management department and
doing ANY appeals, make sure you cc your husbands Human
Resource director (or the person in charge of buying
insurance for his company) and the President of the
Insurance company. From there also call your state’s
insurance regulater and lok for the laws of the state which
all insurance companies operating within that state
must adhere to. And lastly keep ALL documentation of
all contact with the insurance company and your
husbands employer. I am sure you will get you wishes…
but it will be hard work…. just remember YOU are
worth the fight!<br>Cindy<br>open RNY 8/2/99<br>preop
298<br>current 185
December 4th, 2003 at 12:03 am
Hi. I usually don’t post to this board but I had
to answer this one. My husband’s company also has a
PPO or self-funded insurance. See how it works is the
company pays into the insurance and it is also the
company who dictates what they will and will not cover.
The insurance company you deal with is really just
the administrator for your husband’s company. They
make no decisions on what to cover. In my case I
battled with the administrators for 2 months over this
surgery before I finally called the company OWNER. This
is a small company and my hubby is 7th. in command
so to speak so I was comfortable doing this. I was
told by the owner that they woulod look into it, which
they did, and when they found out they had to pay
$45-50,000 they said no. Period. There is no review board or
anything to appeal to because this came direct from the
owner. And also I called the Dept. of Labor for my state
(Ohio) and asked to talk to someone about self-funded
companies. In my state self-funded comapnies are required to
provide coverage ONLY for newborns and mental health
issues. They are required by law to provide no other
coverage. So call your Dept. of Labor for MI and ask what
your laws are. My surgeon offers a "discount" cash
price for people like me of $16,000 so we took a second
on our house to pay for it. Good
Luck!<br><br>Cynthia<br>Pre-op<br>Open RNY<br>June 2, 2000