question for alexandra

dishdiva · December 3, 2003

Hey Alexandra,

Because of your work, I think you have one of the best perspectives on insurance issues of anyone. Long story short -- I'm still trying to get my claim paid from surgery last August. (The surgeon's office obtained verbal approval from a high level Cigna exec. and failed to get it in writing, as did I. If it was good enough for the people who were going to get paid, it was okay by me. Lesson learned!)

Cigna PPO denied my initial claim and first appeal. I was ready to hire Walter Lindstrom (Obesity Law Center) to handle my second appeal. Then my surgeon's office called today after contacting the state insurance commisioner's office...and was told our plan was self-funded and I needed to contact my benefits administrator, which I did.

My question for you is: what exactly does self-funded mean? I'm trying to figure out if my odds have improved! It's worth about $20K to me!

Thanks!

Elizabeth

P.S. Love the new pic :rolleyes:

Alexandra · December 3, 2003

Hi Elizabeth,

"Self-funded" means that you are covered by a large-company plan that insures itself. They hired Cigna to act as a third-party administrator to do the actual work of processing claims and paying them, but the coverage decisions are (or were) made by your own employer.

Your chances may or may not have improved, but from what you say I'd guess the original information from the Cigna exec is worth the paper it's printed on (that is to say, not much). That person may not have known that your policy is not a standard Cigna plan, and might have just been telling you that Cigna covers the band as a rule. But all bets are off when you start talking about self-funded plans.

The good news is that the maker of the rules can also change them or make coverage decisions on a case-by-case basis. Your benefits administrator will obviously have a contract to go by (which will say whether surgical treatment for morbid obesity is covered or not--a basic and important thing you must find out), but you'll be able to appeal more directly to the decision-makers if you need to.

Good luck!!