On 6/18/2009 I called my insurance and was told that the lap band was covered, she even walked me through finding the papers to print out about it. I went through all the hoops of a six month diet and everything, had all my papers filled out and was ready for my surgery. The lap band doctor turned in all my papers to the insurance for approval and it came back denied and said that they didn't cover it.

I called up my insurance again today and the lady looked back through my files and said that it was never covered and she could see when I made the phone call on 6/18/2009 and she could see that the lady told me that I was covered.

But all she said that I could do was make an appeal and she didn't sound like my chances were good.

This is so unfair, I was so close, should I get a lawyer to write the appeal or what else can I do? Please help.

No need for an attorney to get involved. Just put together all of the facts, name of who you talked with, date, time, what they told you, the forms you completed, the steps you took following the customer service representative's advice, leaving out all the emotional pleas. Just state the facts, you followed the advice you were provided, and ask for reconsideration.

I would absolutely have an attorney write the letter. If you write an appeal, nothing will happen. If the policy DID cover the surgery and you were denied, then writing an appeal yourself would suffice.

In your situation, your coverage was misrepresented and an attorney will be necessary.

Thank you both for your help. It turns out that my surgeon's office has their own lawyer that will help me out with this at no extra cost. That made me feel a little better. I really hope they don't get away with this, I'd be happy if they'd at least agree to pay half because of this mess up.

Thanks again. :biggrin:

[QUOTE=Mrs. Plumpy;1445514]On 6/18/2009 I called my insurance and was told that the LAP-BAND® was covered, she even walked me through finding the papers to print out about it. I went through all the hoops of a six month diet and everything, had all my papers filled out and was ready for my surgery. The LAP-BAND® doctor turned in all my papers to the insurance for approval and it came back denied and said that they didn't cover it.

I called up my insurance again today and the lady looked back through my files and said that it was never covered and she could see when I made the phone call on 6/18/2009 and she could see that the lady told me that I was covered.

But all she said that I could do was make an appeal and she didn't sound like my chances were good.

This is so unfair, I was so close, should I get a lawyer to write the appeal or what else can I do? Please help.

Hi Mrs Plumpy,

I have a very similar situation. My ins is Anthem bc/bs of Ohio who has a contract with Verizon. Verizon has overridden some of the Anthem benefits so it's not exactly the same. I'm a verizon retiree. I called the member # on the back of my ID card 4 times giving them all my info to verify I'm covered w/ a 36 BMI. Each time I was told yes. I also sent an E-mail and received a positive reply again. My ID # automatically identifies me as a Verizon retiree subscriber. Allergan also has info on the benefits of a lot of ins co's and their website showed it was covered w/ 36 BMI and one co-morbidity and even includes Verizon. Anthem says that info is no good because it comes from a 3rd party. The mistakes that Anthem kept making with me is that their reps never checked the Verizon contract to make sure VZ's policy was the same. I went through all the necessay steps required by my surgeon and was given a pre-op date (5/12) and surgery date (5/20) by my DR pending ins approval. No problems were anticipated since we checked in advance and I met the guidelines. Well, this past thurs, Anthem called me and said I did not qualify because VZ's contract overrode Anthem's policy (ok for 36 BMI) on Bariatric surgery - VZ required a BMI of at least 40. Anthem's stance was that VZ makes their own rules and they have to abide by them so they were going to send me a denial letter. I have since provided them the E-mail stating I qualified (w/36 BMI) from one of their cust svc reps. Their Medical Director is now reviewing my E-mail. They said if they gave me incorrect info, they would approve the surgery anyway to make things right. Allergan will help to appeal if necessary and I'll have an atty which might cost a very small fee. Let me know how you make out and I'll do the same.

Priscilla

Edited May 2, 201016 yr by Golferette
wrote a phrase twice

I'm glad your insurance is going to do the right thing and pay for your surgery because they told you wrong. Mine isn't though, they are not budging and do not care that they told me wrong and I jumped through all these hoops. I could have already had the surgery last year and my back would not have started hurting a few weeks ago, I would have been healthy by now.

But when I told my mom what happened, my grandmother was listening in as well (speakerphone) and she is going to pay for half of the surgery cost, so it will not be too bad on the finances. :thumbup:

My surgery date is May 17th and I start my pre-op diet tomorrow! :thumbup: I am so excited about my surgery that I have tried to forget how the insurance company treated me, I'm looking ahead.

I hope everything goes smoothly for you, I'm sure they will approve you and everything will be fine. :smile:

Mrs. Plumpy;1457540]I'm glad your insurance is going to do the right thing and pay for your surgery because they told you wrong. Mine isn't though, they are not budging and do not care that they told me wrong and I jumped through all these hoops. I could have already had the surgery last year and my back would not have started hurting a few weeks ago, I would have been healthy by now.

But when I told my mom what happened, my grandmother was listening in as well (speakerphone) and she is going to pay for half of the surgery cost, so it will not be too bad on the finances. [/i] :thumbup:

My surgery date is May 17th and I start my pre-op diet tomorrow! :thumbup: I am so excited about my surgery that I have tried to forget how the insurance company treated me, I'm looking ahead.

I hope everything goes smoothly for you, I'm sure they will approve you and everything will be fine. :smile:

I still think you could win if you had the help of your DR's atty. I'd give it a shot but I can understand where you now have a date you just want to get it behind you. Good luck!

Priscilla

Yeah, the lawyer said that this happens alot and they have only paid for a mistake like this 3 times in the past ten or so years. :blushing:

I don't remember if I mentioned this but the insurance is bc/bs of Illinois because the corporate office of the company of where my husband works is in Chicago even though we're in Ohio. So if anyone has this insurance be careful when you call up and ask if you are covered.

Thanks Priscilla, good luck to you as well. :thumbdown:

Hi Mrs Plimpy (love that id),

I have an update on my bandster. Go to Golferette's story at the bottom and see the 5/3 update.

Priscilla

Wow, I read the update and I really hope the insurance gets their act together for you and quickly, surely they see how urgent this is and they won't make you wait that long for approval.

I have been told before to just keep calling and asking about it so just keep trying and I hope everything turns out ok for you. *hug*

Wow, I read the update and I really hope the insurance gets their act together for you and quickly, surely they see how urgent this is and they won't make you wait that long for approval.

I have been told before to just keep calling and asking about it so just keep trying and I hope everything turns out ok for you. *hug*

Mrs Plimpy - See my update today on my bandster

'MY STORY". Anthem lied about making things right if they gave me incorrect info. Arrrgh! Priscilla

Hang in there and keep trying. It makes me so angry that these big companies can get away with stuff like this. Even if they offered to pay some of it would be a gesture they were sorry but they don't even want to do that.:thumbup:

Don't give up! :thumbup:

Hang in there and keep trying. It makes me so angry that these big companies can get away with stuff like this. Even if they offered to pay some of it would be a gesture they were sorry but they don't even want to do that.:thumbup:

Don't give up! :thumbup:

Thank you and best of luck to you!

Priscilla