Question:
if your insurance is not self funded--meaning the company is fully
insured..is it possible for Human Resources to over turn a denial??? I submitted for a revision and was denied to to the typical exclusion ..surgical treatment and non surgical treatment of obesity including morbid obesity..I have been told yes they can..I have been told no they cant..I am so confused..I have united health care choice plus..thanks — tylerswife (posted on February 18, 2005)
February 18, 2005
No. In a fully funded plan, the insurance company pays for the surgery, so
your company gets the insurance they paid for and nothing more. This
doesn't mean you can't appeal the exclusion itself, but it isn't likely to
work -- but it HAS been done. A lawyer would have to advise you whether
the exclusion is proper.
— [Deactivated Member]
February 18, 2005
If the company is fully insured, the insurance company makes the final
decision. With self funded companies, the employer can make the final
decision. However, the HR department could send in a letter on your behalf
but I doubt it would carry that much weight with the insurance company.
— Patty H.
February 18, 2005
You have an exclusion in your policy your EMPLOYER was the one that
'bought' that type of policy. No they cant over ride it if they are
'buying' insurance from the company. But they can 'change' the policy they
buy next time around.
— star .
February 18, 2005
A Self funded group means that the place of business provides the funds in
which it pays the claims. The insurance company only manages the insurance.
Yes, a self funded group can overturn a decision made by the insurance
company. I know this because i work for a insurance company.
— ElliePie
February 18, 2005
No the HR department of your company can not overturn the UHC denial on a
non-self funded policy. However, they can opt to add a WLS rider for the
next open enrollment if they have over a certain number of
employees.....for an increase in everyone's premium. The only way the HR
department can override a denial is if the policy is fully self funded and
UHC were only acting as the administrator. I have personally seen that
happen, but only with self funded policies.
— RebeccaP
February 18, 2005
My experience with UHC is that it all depends on the number of employees
the company has. If it is over 100, the company has options to
"cafeteria" pick what it wants to include in their plan. Small
businesses do not have that option. This is specific to Texas. Other
states have different regulations.
— Gail W.
February 19, 2005
Rebecca, my experience is exactly the same that Gail is experiencing, we
both live in Texas and for small companies, UHC does not give WLS as an
option. My HR tried and hit dead end streets on every avenue. I am
self-pay and after my surgery I will be writing to our state legislature to
fight this for future WLS candidates. Best of Luck ~~ Dana
— cajungirl
February 19, 2005
Texas is a whole nuther animal. Texas has passed so many laws to protect
their residents that it is actually hurting those that live in your state.
So many insurance companies have pulled out of the state of Texas because
of their regulations. The state of Texas decided to randomly audit several
large insurance companies for all claims paid in a year time period. I
worked at UHC when they did this and they wanted it done in a matter of
like 6 weeks. With all of the claims that were paid in the time frame they
were looking for would have taken something like 100 employees working 24
hour shifts to get it all done. The state finally decided to lessen the
time frame and pull only a sample. This was just random...no reason other
than 'let's see if they are compliant.' Sadly, most insurance companies
charge more for those in your state because of the regulations.
Regulations that actually protect the providers more than they do you. And
you pay more for it. Just food for thought. Rebecca
— RebeccaP
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