Spiky Bugger
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I Have Another Insurance Question?
- Thread starter robs477
- Start date
robs477
Now an Angel in heaven
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Thxs Spiky, like I need one more thing to do...lol. Wow...Diana, I didn’t even think about that angle, great point. I live my whole life with a plan A, B, C etc, I always have an exit and try to anticipate failure, as a result, every once in a while, success happens along the way.
So, obviously, the easiest, safest plan would be to just keep my Wife on my Insurance for a couple years, to mitigate any potential complications. Costs for her insurance vs being added to mine are comparable, so that’s not the problem. But, here is where it takes a turn….actually, more of a twist.
My Wife and I have legal guardianship, conservators over our Granddaughter and are Grandparents raising our Granddaughter of 11, for the last 10 yrs. Though we have 100% full legal managing conservatorship over her, the Company I work for will not allow me to put her on my insurance because they have a clause that says that the “Birth Parents” have had to surrender their “Parental rights” in order for them to recognize her as a “Dependent”. Though we have 100% legal custodial conservatorship, we did not have them relinquish their parental rights 10 yrs ago, in the hopes that they would maybe someday grow up, which never happened. My Wife’s company does not have that requirement and she is on her insurance….so, If I switch my Wife for the WLS, I was only hoping it would be for 2015 because of the baby.
My only alternative may be to go out on the market and get a standalone policy for the lil one. Expecting the unexpected is why I asked you guys! Thxs SO MUCH for your time and expertise, it is so appreciated! And yes, Diana, I will try to get her exclusions and such, thxs.
If I am not wrong, it depends on the Evidence of Coverage (insurance policy) and how it is written.
Best thing would be to get a copy of your EOC and read it thoroughly.
Can they? Yes. It is more rare now, since the ACA required that preexisting conditions be covered, but I still think it is a risk because (1) not all policies are governed by ACA (yet); and (2) if they can exclude bariatrics, they can exclude complications and consequences of having an excluded procedure.
Larra
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Coverage for complications is a good point, which is another reason to start hoop jumping asap and get her surgery done asap. Most complications, esp the serious ones, show up fairly soon post-op. Certainly a leak or a stricture would be evident in the first few weeks post-op. Same for wound infection or abscess. The further out you get from the surgery, the less likely a complication will show up. Reflux, maybe later, but the treatment is meds that any doctor an prescribe (or even otc stuff like Prilosec works for many people).
robs477
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Well, looks like Diana may be right, again, as usual!!...What a surprise!...lol Diana, I just got the copy of my wife's policy and am going to try to PM it to you because there is some personal info on the .pdf. The things I noticed are:, It looks like they may have "Trojan Horsed", snuck that in there actually under the "Covered Expenses" section: It seems like it is purposefully written to be ambiguous and open to subjective interpretation and selective enforcement as needed. There looks like a lot of exits for them regarding any after effects of any non-covered procedures.
COVERED EXPENSES
On page 26
Covered expenses include charges by a physician or hospital that:
• repairs an injury incurred during a covered surgical procedure, provided that the surgery is performed no later than 24 months after the initial injury;
Here are some highlight from the exclusions:
Restrictions and Exclusions
Expenses not covered
On page 34
Drugs, medications and supplies: o over-the-counter drugs, biological or chemical preparations and supplies that may be obtained without a prescription including vitamins;
o any prescription drug purchased illegally outside the United States, even if otherwise covered under this plan within the United States;
o drugs related to the treatment of non-covered expenses;
On page 38
Services and supplies provided in connection with treatment or care that is not covered under the Medical Plan.
On page 40
Weight: Any treatment, drug service or supply intended to decrease or increase body weight, control weight or treat obesity, including morbid obesity, regardless of the existence of comorbid conditions; except as provided in this SPD, including but not limited to:
o liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery; surgical procedures medical treatments, weight control/loss programs and other services and supplies that are primarily intended to treat, or are related to the treatment of obesity, including morbid obesity;
o drugs, stimulants, preparations,
COVERED EXPENSES
On page 26
Covered expenses include charges by a physician or hospital that:
• repairs an injury incurred during a covered surgical procedure, provided that the surgery is performed no later than 24 months after the initial injury;
Here are some highlight from the exclusions:
Restrictions and Exclusions
Expenses not covered
On page 34
Drugs, medications and supplies: o over-the-counter drugs, biological or chemical preparations and supplies that may be obtained without a prescription including vitamins;
o any prescription drug purchased illegally outside the United States, even if otherwise covered under this plan within the United States;
o drugs related to the treatment of non-covered expenses;
On page 38
Services and supplies provided in connection with treatment or care that is not covered under the Medical Plan.
On page 40
Weight: Any treatment, drug service or supply intended to decrease or increase body weight, control weight or treat obesity, including morbid obesity, regardless of the existence of comorbid conditions; except as provided in this SPD, including but not limited to:
o liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery; surgical procedures medical treatments, weight control/loss programs and other services and supplies that are primarily intended to treat, or are related to the treatment of obesity, including morbid obesity;
o drugs, stimulants, preparations,
Rob, if you click on an avatar of the person you want to send a PM to, it is called Start a Conversation and I BELIEVE I have it set to include attachments.Ok, I must be a moron...I don't see a way to send a PM, so, I'm just attaching the .pdf. Hell, we don't have anything to hide on this site anyway the way everyone shares poop stories and such the way you'll do
Also listed in the EXCLUSIONS, on page 37 of the document:
"charges as a result of complications from any service excluded from coverage under the Medical Plan"
Yup - this plan sucks. I hope you can find some other way to get coverage for your granddaughter. Perhaps you can talk to your plan administrator to see if you can get a waiver, or a change in that contract term regarding coverage under YOUR plan?
"charges as a result of complications from any service excluded from coverage under the Medical Plan"
Yup - this plan sucks. I hope you can find some other way to get coverage for your granddaughter. Perhaps you can talk to your plan administrator to see if you can get a waiver, or a change in that contract term regarding coverage under YOUR plan?
robs477
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I actually put in an official appeal to my company a few years ago when my wife lost her job due to the demise of the Shuttle program and was denied. They wouldn't budge, so, it looks like Plan "C", keep my wife on my insurance for at least 3 or 4 years and go public for my granddaughter. Its, no big deal, because we are better off with out her crappy policy anyway that was costing us as much to add her on to mine. We will just have the additional expense for the granddaughters public policy whatever that may be. BUT, at least we know FOR SURE what direction to go!! Thxs to you wonderful expert and helpful and brilliant Ladies! If I could, I would buy you some flowers to say thank you!
You should have a conversation with public plan people directly - it is possible that, since you are NOT legally obligated to support your granddaughter, your income is irrelevant to HER insurance - it may be based on the income of the person(s) actually legally responsible for her coverage.
robs477
Now an Angel in heaven
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Another good point, per our managing conservatorship court order, we being the managing conservators are suppose to provide her insurance, but the document says they are supposed to pay for it. We also nailed the worthless subhuman "birth father" with $300 per month in child support which he's never paid, (a whole other subject), so it may be worth looking in to, at least we will let his bill keep getting higher, its currently somewhere in the $40K range.
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