Employer Doesn't Have Rider - Has Anyone Dealt With This

[aramey75 1]

I am so utterly rejected.

I was mid-process a few years ago when I had to change employers due to family reasons. We had to change our insurance to my husband's provider that did not cover WLS. Imagine my excitement when we got notification that they were changing providers to BCBS (VA) - which I knew covered WLS. So, I started over again.

Went to the information session. Made the appointment with my surgeon for next week. Got the insurance cards in the mail over the weekend. Called the provider, and confirmed that the employer does in fact carry the rider. An hour later, had to call back for another question. Spoke with a different person. They saw something different. So, after an hour on the phone, emails flying between BCBS and the plan administrator for the employer, and my husband and HR. It is not covered.

So - my question is this. Is there anyone here who has fought this with their EMPLOYER? And won? What can I do? Anything? The worst part about it is, we tied ourselves for the next 15 months to the highest plan his employer offered because of the hospitalization benefits. We wouldn't have gone with it, otherwise.

Thanks in advance for your help!

[FLORIDAYS 3,040]

I am not sure how you can fight a coverage issue because I would think if its not covered it not covered...Mine wasnt so I got creative with my Dr and went in as a self pay.

However regarding your insurance... open enrollement is usually once a year so I am not sure how thats 15 months until you can make a change in the policy. Unless you have a life changing situation... thats usually a divorce, marriage, birth or emplyment change.

Do yuu have insurance where you work? If so you could add him to yours if its cheaper... Just a thought.

Good luck!

[2muchfun 8,928]

I too was covered by my wife's insurance program and her employer's plan did not cover WLS. Then, in January when open enrollment came back around we changed to a different plan that was also offered by her employer. It did cover WLS so I eventually had surgery.

WLS is like adding an addendum to your homeowners insurance covering your large jewelry collection. They will charge you for this. You have to understand that each of these add-ons increase the cost to the employer who may or may not pass that along to the employee in a higher cost, deductible or co-pay. If there are 1000 employees all contributing to the pool with higher fees, this helps to mitigate the cost of WLS to the insurance co. If each employee has a higher per year cost of let's say $50, that would pay for 4 lapbands and allow the insurance company a little profit.

So, the cost of the surgery would have to come out of the pockets of you, the employer or the insurance company. Since no plan existed and the extra cost was not contributed by the members, I'm afraid the cost falls back on you. It's just basic math. Having the employer pay for it would be considered a bonus I would think?

tmf

[aramey75 1]

Its 15 months because they changed policies mid year. Our open enrollment was in August for October, 2012 - December, 2013 so they didn't have to do another round of open enrollment after just 3 months and they can get it back to the calendar year cycle starting January, 2014.

I really do understand the mechanics behind the rider system. I really do. I just wasn't sure if there was anyone out there who was able to appeal to their employers and actually win.

What irks me is that Medicaid covers it. I pay for that through taxes. However, my husband works for a government agency. So essentially, they'll cover it through Medicaid but not for their employees. (He is local government, not state).