UHC restriction

[MellyBean1984]

Hello all. I'm curious if anyone has ever heard of this restriction. United healthcare paid for my sleeve in 2014. I'm wanting a revision to DS with Dr. Ayoola. I gave them all my info, his office called and left a message that said I have a $50,000 limit on bariatric surgeries. Which I knew. They also said I have to wait 5 years for a revision surgery. I'm curious because I've never read anything like this in my policy and I've never heard of anyone else having this issue. Have you ever heard of this? Is it something I possibly overlooked?

 

[Munchkin]

The first thing you need to do is get a copy of your real EOC. Should be @100 pages or so and actually READ your policy. Please post it here and you will get all kinds of help!

 

[Clematis]

The only way you can know is to get your Evidence of Coverage (EOC) a lenghthy (about 100 pages) document with the details of your individual policy.

 

[Clematis]

Ha, Munchkin beat me to it by seconds.

 

[Spiky Bugger]

Also--and I'm not the expert here--I would think there is a difference between a revision procedure needed because the original isn't meeting goals and a revision because the original procedure is causing problems and has to be undone whether anything new is done in addition. I would think that ins companies would rather, for example, pay to remove a troublesome band and do a revision to sleeve or DS at the same time, than to pay for two surgeries...especially if the insured is close to that five year mark.

That foolishly assumes that ins companies would elect to make reasonable decisions...which they never do.

 

[MellyBean1984]

I'm definitely going to call tomorrow and get the evidence of coverage. I wasn't aware this existed until I saw it on here this weekend.
Unfortunately I had to get involved with this on a 3 day weekend I'm just shocked because I haven't heard of a 5 year waiting period with any insurance company so I wonder if maybe they're talking about the 5 year weight record. Of course all policies are different and if they can screw you over even a bit they will! I know from the past talking to 3 different people can give you at least 3 different answers.
Spiky that would mean the insurance companies would have to be reasonable and actually care about the insured person. If they do that they might lose a little bit of $$$ Of course they'll lose more paying for someone who develops diabetes or anything else over just paying for the DS. Our insurance company is either great or horrible no inbetween. They do awesome paying for our son's Occupational Therapy. Over $2,000 a month. However they won't pay $300 a year for insoles for my husband's shoes that prevent a $30,000 surgery and extra doctor bills and that keeps him off work for 3 months... but if we have to pay for one I'm glad it's the $300 a year insoles!

 

[southernlady]

I don't think it's UHC, it's your employer. As others mentioned, get your EOC first.

 

[MellyBean1984]

That's very true I didn't think about that. Who should I get in touch with about getting my EOC? My husband's employer or UHC? Thank you all for the advice!

 

[Clematis]

It might be on UHC website after you log in however it is not always called "Evidence of Coverage" (they don't make it easy). Just keep digging around until you find something L-O-N-G. If you don't find anything online, try the employer. They are unlikely to actually have it but they can contact UHC for you as ofttimes the insurer responds swifter to an employer that to an individual. You could ALSO contact UHC directly. I actually had to sign a form before they'd send it to me. So weird -- this is in effect a contract and I have to fight to get a copy?? Geez.

 

[DianaCox]

If this is employer-provided insurance, the insurance contract is between the employer and the insurance company. The employer has the EoC or can get it - you can't get it from the insurance company itself. Get your husband to ask HR for it.

 

[LindaDarnell]

I'm no expert but I've been insured under UHC for almost 18 years through 4 different employer plans, and I can tell you that when it comes to WLS it is all on the employer. I've been under my hubby's UHC plan where WLS was treated like a menace to society, never to be discussed. Under my current employer's plan Ive had VSG, then revised to DS, hubby has had DS...no restrictions, denials, pre-diets, or obstacles in either situation. Just met the BMI and comorbidities, and approved. We were even assigned to a bariatric nurse caseworker that helped navigate questions with the doctors for pre-op and post-op care.
It is definitely the employer's contract with UHC that determines their response to WLS requests.

 

[MellyBean1984]

Well we got ahold of HR and they said they could give us a list of what we signed up for like vision, dental, etc. but anything else would have to go through insurance. Which we're going to call again because I think the lady wasn't really understanding what we needed. I did call insurance and the guy said I might be able to find it online, when I went on their website and found the coverage and benefits section a window popped up that said something like 'these documents are not available online.' So insurance had told me it might be best to just have the doctors office submit everything for the surgery and then they'll either approve it or deny it and if they deny it they'll send me a letter why. When I asked Dr. Ayoola's office about this they refused to and one of the lady's said "Well insurance isn't going to cover it, if you guys want to go... or you can wait to see him but his self pay cost is $12,800" I told her, which I had already told them several times "IF insurance isn't going to cover it that's fine I'll self pay either by going through a financing or something else." I had read on Dr. Ayoola's website that they work with a financing company, so when I asked about that first she told me "No we don't work with a financing company." I said "His website said he does..." She said "Oh yeah. We work with care credit" Then when I asked about the hospital price for self pay, because obviously if I'm getting a loan I need to know roughly how much, she said "oh yeah I don't know. Maybe $30,000, I've seen $32,000" I'm about to cry dealing with this! I really want him to be my surgeon but if I don't know how much to pay, or if I can't get them to work with me on anything it makes me wonder if it's worth it... She really treated me like an inconvenience.

 

[southernlady]

Have you considered going to Mexico to Dr. Esquerra. He would be much less expensive and since all you are doing is adding the switch to the sleeve, he can easily do that. http://bariatricfacts.org/threads/dr-gilberto-ungson-mexicali-mx-now-dr-esquerra.1747/

 

[MellyBean1984]

I think I'll probably need my sleeve actually redone as well. I haven't had much restriction, even in the beginning I didn't. However I have really been considering him. I never thought I would but it maybe worth it. I have heard stories about people not being able to find doctors that will treat them and insurance companies don't want them since they had surgery in Mexico. How much truth is there to that? Of course a majority of these stories I've heard from someone in the medical field sooooooo...

 

[Clematis]

Mexico schmexico. I was told no surgeon wants to treat another guys patient from another STATE. They just don't know what they're gonna find in there and if they will then be sued for something they didn't do in the first place. Esquerra videos all his surgeries do you can always show another doc that. I have nothing but good things to say about Esquerra - and I had zero intention of ever going to MX. Haha. They keep you in the hospital for 4 nights - long enough for complications to occur and be treated if you have them. (It seems that the complications I hear of with US surgeons would have been easily dealt with if patients weren't given the bums rush after 24-36 hrs)

Oh no way would I begin the revision process using insurance without having my EOC in my hands to read.

Good luck!