Cigns Insurance denied for pre-existing condition

murphyraven

I was denied benefits (after being told I was covered for VSG and starting the diet, appointments, etc) due to a "pre-existing" condition clause. What it sounds like is that Cigna can deny me because I did not have medical insurance for over a year previous to my husband adding me to his plan. That they consider being morbidly obese as a pre-existing condition does irritate me though. I am trying to become healthier to AVOID type 2 diabetes, high blood pressure, etc. In the long run this surgery will help me be healthier and not spending as much on healthcare expenses.

The surgical center is helping me appeal the decision and trying to get the surgery approved. Worst case scenario is that I have to wait until march of 2015 before they will cover the surgery.

I stopped tracking my food and had a mini pity party for a couple weeks. Then I decided surgery or not I need to keep my chin up and continue to follow the plan. I lost 17 lbs in 3 months following the supervised diet without much exercise. Some people have to follow a 6 month diet plan. If I have to wait a year then so be it. I will follow the program and be in that much better shape for the surgery when/if it happens.

I was just barely over 40 BMI when I started the process. I am making sure that if I have to wait until march to get approved that I don't have to redo the nutrition appointments, and that my starting BMI will still be counted. As much as I didn't want to wait I know that being able to stay on track with my diet through these trials will help me be successful in the long run. This is a not a race its a life change that I need to take one day at a time.

weeziebeth

By no means do I understand the Affordable Care Act in all its detail, but pretty sure it eliminated pre-existing exclusions. Since this is a federal law and not state, this means even self-funded programs (which many large employers have) are subject to it. While the insurance company/plan/etc can choose not to offer WLS as a benefit, if they do offer it, they cannot deny it as the result of a preexisting condition.

rpyle111

Bummer that this is happening to you.

I think that the slow boat is not necessarily a bad thing, though. 7 months of the good behaviors will give you lots of confidence that you are able to follow the new life you are choosing.

Trying to see the positive,

Rob

MyOwnSunshine

I know that my insurance (a self-insured plan from a health system) requires a 2-year waiting period (clarification: the insured must be on the plan for 2 years) before coverage for WLS is provided in order to avoid people switching jobs or switching insurance plans to get the surgery and then quitting/switching back.

While it is miserable for you, I do understand why they do this. WLS is not a universally covered procedure. I would imagine they are within their rights. Although it seems like a long wait right now, surgery will still be there for you in March if you want it.

Edited for clarity.

homerismyhero

Pre Ex is tough. The ACA did away with it in most markets/ plans, but there's still a few "Grandfathered" plans, or small markets where it's in place. Try to hang in there and continue on the path and even if you have to wait until March, at least you will have already made some good habits that will contribute towards your sucess post surgery. I had mine in March 2014 and in some ways I felt like that was the best time of year- good weather so excercizing outside and getting to the gym was easy- and by the time summer came I could fit into things that were comfortable for the weather. It's a very small sivler lining- but it's something!

katematt313

That is horrible! I also thought the ACA eliminated this issue. Maybe there are other healthcare options that don't have the gap/coverage restrictions that you can investigate?

Be glad you are learning about this now, and can resolve it before you have WLS.

I have a child who is a cancer survivor. During her treatment, we switched insurances because my husband got laid off. The second insurance company, through my employer, attempted to get out of paying for 2 major surgeries, and months of tests, hospitalization, etc., because they claimed that we had a gap in coverage (which we did not have). Proving to the carrier that there was no gap in coverage was easy to do, but it took a huge amount of time to get through their red tape and actually get the bills paid, all of which ended up going into collection. We ultimately had to get the State insurance commission and the State healthcare advocate involved (glad we live in CT and have these resources), because 100K+ worth of bills were not getting paid, and we were getting horrible phone calls at all hours of the day, like we were thieves. It was a nightmare, on top of a nightmare.

I am so glad that this is behind us. This experience is the one reason that I have become a stalwart supporter of universal healthcare. We are lucky to have never been without insurance. However, our situation proves that for-profit healthcare is really not good for patients and their families.

pawoodhull

Although this really sucks, I have to say I admire your attitude! You had your pity party and are now back on track and determined to succeed! I love what you said about this not being a race, but a lifestyle change. So true! I'm 3 years out and still not to goal. I will get to goal at some point, but my life and health is so much better for the weight loss I do have, that not being to goal yet is a small irritation. Liek you, I know this is not a race, but a tool that allows me to lose and keep off the excess weight. So, it allows me to get and stay healthy.

Hang in there. I will be praying the doctor's office is successful in fighting the insurance company and you get your WLS sooner rather than later.

Pat

JxAAA

Check out this link, I don't know that they're allowed to deny you covered services based on a pre-existing conditions. They may be able to make you wait but deny all together doesn't sound right.. I know there are some exemptions but a national carrier like Cigna, I doubt they meet the qualifications for the exemptions.

http://obamacarefacts.com/pre-existing-conditions.php

authorwriter

My husband's BCBS plan specifically excluded WLS because it's a self-funded plan. I got on the horn to BCBS and got myself an individual plan that does include Bariatric surgery. I'm switching back to my husband's plan at the end of the year. I took the smallest deductible etc plan I could get. the premium is hefty, but the cost, overall, worked out because the surgery was covered, including a surgery they don't normally covered and I quickly met the deductible so everything else I'm getting done is free until the end of the year. yes, you can bet I'm doing all the preventative stuff and taking every one of my physical therapy sessions for my back and any imaging and consults, etc.

Insurance can't deny you coverage for a pre-existing condition anymore. And that's what made it so easy for me to purchase the insurance that would cover what I needed covered and why I can switch back without an issue at the end of the year. Because my WLS will be a preexisting condition and my husband's insurance will have to cover any problems that might arise as a result. which they say they do, anyway.

murphyraven

The insurance rep from my surgery center is still fighting with Cigna on my appeal. We followed the appeal process but didn't hear anything, when she checked with Cigna the answer changes depending on the rep she speaks to. One person said the appeal was entered and being considered, another says there is no appeal in the system and that we don't even get an appeal (but we have papers saying we do). Its been a frustrating and disheartening experience. Part of me just wants to throw in the towel and go to Mexico for self pay option but the other part of me want to make Cigna pay for this surgery at all costs. Trying to stay positive and wishing I could throttle the insurance industry.

boomerkae

Good luck! How horrible to go through. My request was submitted to insurance yesterday, so I'm in the waiting game. I have no co-morbidities, so i have to maintain a BMI of 40+. Not sure how it works for your insurance if the appeal isn't approved, but for mine, I'm hearing BMI at consent, not at start or when the paperwork is submitted. After losing 25lbs on the pre-op nutrition/diet, I now have to maintain or risk falling under by the time of consent - which is right before surgery - or being denied.