Insurance Questions

[Doctorblue]

I talked to Dr. Ayoola’s office. They told me I did have Bariatric coverage. I was an idiot and mentioned that that made me happy because the initial person I talked to told me I didn’t have coverage (why did I open my stupid mouth?!). So, his office said that made them nervous, so they’re going to double check my coverage.

Found this in my coverage benefits. Is this fightable? Larra DianaCox

 

[Larra]

It does indeed read like an exclusion to me. It is very disturbing that such exclusions should be legal, but they are. Perhaps others will read this differently, but that's how I read it.

 

[Doctorblue]

It does indeed read like an exclusion to me. It is very disturbing that such exclusions should be legal, but they are. Perhaps others will read this differently, but that's how I read it.

Thank you so much for responding. I appreciate it. I can kick myself for opening my mouth. Are exclusions pretty much a done deal or are they able to be appealed successfully? Should I start trying to save up for self-pay?

 

[Larra]

It is unlikely that you can get past a complete exclusion, but I think DianaCox can answer that better than I can. It would almost certainly involve an external appeal (assuming an external appeal is an option - check your document for that info) and even then this is a contract, and will likely be upheld.
BUT stop kicking yourself for speaking up. When the surgeon's office submitted for authorization, your insurer would have cited the exclusion and you would have been denied, so just as well to know where you stand now.

 

[Doctorblue]

BUT stop kicking yourself for speaking up. When the surgeon's office submitted for authorization, your insurer would have cited the exclusion and you would have been denied, so just as well to know where you stand now.

Thank you for that. After I was done throwing myself a pity party, I came to a similar conclusion. I told my husband, it’s better to know now, than to think I’m covered, get the surgery, and then, “SURPRISE, you owe 25K.”

 

[Doctorblue]

It is unlikely that you can get past a complete exclusion, but I think DianaCox can answer that better than I can. It would almost certainly involve an external appeal (assuming an external appeal is an option - check your document for that info) and even then this is a contract, and will likely be upheld.

Appeal procedures C&P'd below. Also attached the EoC. Sounds like I'm most likely looking at self pay.

Level One Appeal
Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will be considered by a health care professional.

Level Two Appeal
If you are dissatisfied with our level one appeal decision, you may request a second review.

Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's level two appeal review regarding your Medical Necessity or clinical appropriateness issue, you may request that your appeal be referred to an Independent Review Organization. The Independent Review Organization is composed of persons who are not employed by Cigna HealthCare or any of its affiliates. A decision to use the voluntary level of appeal will not affect the claimant's rights to any other benefits under the plan.

There is no charge for you to initiate this independent review process. Cigna will abide by the decision of the Independent Review Organization.

In order to request a referral to an Independent Review Organization, certain conditions apply. The reason for the denial must be based on a Medical Necessity or clinical appropriateness determination by Cigna. Administrative, eligibility or benefit coverage limits or exclusions are not eligible for appeal under this process. To request a standard external review, you or your authorized representative must file a written request for an external review with the Arkansas Insurance Commissioner within four (4) months after the date of receipt of a notice of adverse determination. Requests for expedited external review may be made orally or in writing to the Arkansas Insurance Commissioner within four (4) months after the date of receipt of a notice of adverse determination

The two internal reviews mention "Medical Necessity" but don't mention exclusions. The exclusions aren't listed until the Independent Review. If I have any chance (which I understand you saying it's a complete exclusion, so likely there's not much chance), it seems like it would only be in the first two appeals, if I'm reading that correctly.

Thank you for responding so fast. I appreciate your help thus far. I agree, it's just now right how insurance companies can do this to people. Exclusions, and a lot of insurance policies themselves, stink. My Type 1 diabetic husband has been jerked around so many times regarding his diabetes.

 

[Webmommy]

That’s what the wording looked like when my insurance had an exclusion. There was no appealing it either because it was a self funded Federal plan by a big box retailer who can do almost whatever they want. I am glad you have an appeals process!

FYI from my own experience with Dr. Ayoola’s office, listen to what they have to say but verify it for yourself. It was wise for you to do that!

 

[Larra]

The internal appeals are not likely to succeed, but IF you also have access to an external appeal, you will (almost certainly) be required to complete the internal appeal process first. Check to see if there is an external appeal available to you, that's your best chance for success - though I think, with that exclusion, even that is not likely to work. We've seen a lot of people self-pay over the years, and the surgery is so worth it that they're glad they did.

 

[Spiky Bugger]

Potentially Political Starement, although I’m merely stating a fact:

Insurance companies CANNOT do this in states where such restrictions are, by law, not permitted.