New insurance, not covered?

[brooklyngirl]

Hey guys!
I'm hoping for a little advice from those if you who are knowledgeable about insurance policies. I'm attaching a photo of one of the documents that I received from work about the new insurance coverage, specifically- the services and supplies that are NOT paid for. They just told us about his last week and it'll go into effect Jan. 1st. It'll save me a BUNCH of money coming off my husband's policy, but there are a few things that concern me, namely:
1- "any treatment for surgery for obesity, weight reduction, or complications there from, reversal or reconstructive procedures resulting from such treatment"
2- "cosmetic or reconstructive procedures, unless following a mastectomy"
3- "any service or supply rendered to a member for diagnosis or treatment of infertility"

So, does this mean that plastics are automatically off the table even though I have a panni that hangs down to my thighs?
If I have a bowel obstruction at one of the intestinal anastomoses (sp?) is everything in the hospital resulting from that uncovered?
And I'm 36 years old, unable to have children so far, surgeon wants me to wait until the 18 month mark (Feb) to start trying for babies. If it doesn't happen, is even the basic testing to see what the problem is not covered? And then even a simple prescription for, let's say clomid, not covered?
Is this standard or am I going crazy? I don't think I've ever seen a document like this, or have I just not paid attention because all these things weren't important to me in the past?
Finally (for now) any idea how I find out this information for hubby's policy to see if it's better to stay on his? Do I just log on and search for "services and supplies not paid for" or is it better to call and speak to a human?

Bah. Thanks for anyone willing to help me understand!

FIFY...Liz

 

[brooklyngirl]

 

[DianaCox]

Well, isn't that speshul??

You pretty much got everything right - I'm not sure they can refuse to cover surgery for a bowel obstruction, since people who have never had any WLS can get bowel obstructions, and the incidence is increased by any abdominal surgery (e.g., appendectomy), but yes, everything else is EXCLUDED from coverage. I'll bet they would refuse to pay for your yearly labwork too, unless coded carefully (579.9 - intestinal malabsorption, unspecified).

That is a TERRIBLE policy for you. The way to find out what hubby's policy is, is to ask him to ask his HR dept for the Evidence of Coverage document - it should be about 100 pages long.

 

[Larra]

I'm glad Diana posted while I was reading this with my jaw dropping (and I had better not need any treatment for that jaw under this policy!!) This policy really sucks, and not just for you but for lots of other people as well. No wonder it's cheaper, the coverage is so limited! I hope some other, better policy is available to you, even if it costs a bit more.

 

[Spiky Bugger]

Political reply...

NC is bipolar politically. It went Blue for national stuff and Red for in-state stuff. Which usually means LOUSY consumer, including insurance consumer, protection. In a die-hard Blue state, at least a couple of those restrictions would be illegal. You might have to fight for a while, but you would prevail. But...see below.

The rest...
So...any chance you have a "cafeteria" plan, where you can take cash in lieu of coverage or apply the money the employer pays to some other item...like long term care insurance or some other kind of policy?

And your hubby's policy will be secondary to yours, right? Will they cover what this policy excludes?

Finally, is there some kind of state law that MAKES them cover PS after mastectomy? I ask because the way some laws were written, to cover post-mastectomy PS, they MIGHT have been accidentally written in a way that would allow for PS for other conditions. I say this because I know this really argumentative woman who fought that battle (in another state.) She talked about it a lot. And then SUDDENLY, she had ABSOLUTELY. NOTHING. TO. SAY about the situation...which is my clue* that someone paid someone else something, but part of the deal was that the payee had to shut up. So knowing WHY they are willing to pay for post-mastectomy PS might be worthwhile.



*Same keen police mind that told me that when my cardio's office called at 6:30 on a Friday evening (I'd had a CT scan of the heart earlier that day) to make sure I'd be at my Tuesday appointment...and mentioned that I'd still be getting my regular appointment reminder call...that SOMETHING was wrong. Often, it's what isn't said.

 

[DianaCox]

SB: yes, post-mastectomy reconstructive surgery is a FEDERAL mandate: http://www.dol.gov/ebsa/publications/whcra.html. But the law is a particular exception which has as far as I know been crafted so carefully that it cannot be expanded to encompass post-bariatric surgery reconstructive surgery (http://www.gpo.gov/fdsys/pkg/USCODE...ubchapI-subtitleB-part7-subpartB-sec1185b.pdf).

As for that "other person" - I'm pretty sure that she is allowed to say that the case was settled, substantially to her satisfaction. And she certainly is allowed to point to the fact that several insurance companies' policies on reconstructive surgery post-bariatric surgery have since been audited and found lacking (https://www.dmhc.ca.gov/LicensingRe...vey/ViewMedicalSurveyReports.aspx#.VJW4uV4AAA) (interesting how it is now essentially IMPOSSIBLE to find that link on the DMHC site without KNOWING it exists ... it used to be much easier to find). See for example:

• Healthnet (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/300fsnr111113.pdf)
• Blue Shield (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• Cigna (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• GoldenWest (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• Kaiser (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/055full060313.pdf)
• PacifiCare (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/126fs110413.pdf)
• UHC (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/126fs110413.pdf)

Just to name a few.

For some reason, I didn't see a survey that called out Anthem Blue Cross. But they have been dealt with in a separate proceeding: http://gilardi.com/bluecrosslitigation/ (Woelk is a DSer, by the way). $3M settlement was not enough, but not bad - better than a poke in the eye with a sharp stick.

 

[southernlady]

Political reply...

NC is bipolar politically. It went Blue for national stuff and Red for in-state stuff. Which usually means LOUSY consumer, including insurance consumer, protection. In a die-hard Blue state, at least a couple of those restrictions would be illegal. You might have to fight for a while, but you would prevail. But...see below.

Except that SHE is in SC not NC.

 

[Spiky Bugger]

Omg.

Except that SHE is in SC not NC.

..well then...as A. A. Milne wrote:

King John
(Somebody told me)
Said to a man he knew:
"If people go down to the end of the town, well, what can anyone do?"

 

[Spiky Bugger]

SB: yes, post-mastectomy reconstructive surgery is a FEDERAL mandate: http://www.dol.gov/ebsa/publications/whcra.html. But the law is a particular exception which has as far as I know been crafted so carefully that it cannot be expanded to encompass post-bariatric surgery reconstructive surgery (http://www.gpo.gov/fdsys/pkg/USCODE...ubchapI-subtitleB-part7-subpartB-sec1185b.pdf).

As for that "other person" - I'm pretty sure that she is allowed to say that the case was settled, substantially to her satisfaction. And she certainly is allowed to point to the fact that several insurance companies' policies on reconstructive surgery post-bariatric surgery have since been audited and found lacking (https://www.dmhc.ca.gov/LicensingRe...vey/ViewMedicalSurveyReports.aspx#.VJW4uV4AAA) (interesting how it is now essentially IMPOSSIBLE to find that link on the DMHC site without KNOWING it exists ... it used to be much easier to find). See for example:

• Healthnet (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/300fsnr111113.pdf)
• Blue Shield (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• Cigna (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• GoldenWest (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/043fs090513.pdf)
• Kaiser (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/055full060313.pdf)
• PacifiCare (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/126fs110413.pdf)
• UHC (https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/126fs110413.pdf)

Just to name a few.

For some reason, I didn't see a survey that called out Anthem Blue Cross. But they have been dealt with in a separate proceeding: http://gilardi.com/bluecrosslitigation/ (Woelk is a DSer, by the way). $3M settlement was not enough, but not bad - better than a poke in the eye with a sharp stick.

My math is off...if there was $2,189,724 left to distribute to the class members, then Woelk (I know who he is) AND his attorneys, together, got only 31% of the money? Seems like very reasonable attorneys fees and/or damned little money for him.

 

[DianaCox]

My math is off...if there was $2,189,724 left to distribute to the class members, then Woelk (I know who he is) AND his attorneys, together, got only 31% of the money? Seems like very reasonable attorneys fees and/or damned little money for him.

Class action suits: members usually get a fraction (in this case, probably about half) of their actual damages - which were calculated as what they paid for their self-paid surgeries, because of improper denials. No other damages in this case (pain and suffering, etc.). The lead plaintiff usually gets his equal share of the damages plus a modest bonus - high 4 to low 5 figures would be my guess.

 

[JackieOnLine]

this thread makes my head spin (and not in a good way)

 

[Spiky Bugger]

Class action suits: members usually get a fraction (in this case, probably about half) of their actual damages - which were calculated as what they paid for their self-paid surgeries, because of improper denials. No other damages in this case (pain and suffering, etc.). The lead plaintiff usually gets his equal share of the damages plus a modest bonus - high 4 to low 5 figures would be my guess.

But, wouldn't a normal contingency fee have taken 40%, give or take? In this case, the original plaintiff AND attorneys, together, get only 31%?

 

[DianaCox]

Normal contingency is 30-33%, but there are limits in big awards, where the attorney's fees has to not be outrageously out of proportion to the actual amount of work done. When an attorney works on contingency, they are supposed to keep track of their time anyway for that reason. I'm pretty sure that even 1% of $3M or $30K, was in the ballpark of what the lead plaintiff may have gotten (assume that there were about 170 plaintiffs in the class, and they split $2M ($3M minus the $1M [33%] to the attorneys), that would be about $12K apiece, and the lead plaintiff gets a bonus because of the extra work they had to do (depositions, etc.), so $18K extra.

 

[brooklyngirl]

Thanks for the input guys. I was hoping I was understanding all this wrongly. I'm super frustrated

 

[Sheanie]

And we have the ACA to thank for this.