:huh: airmechus, I do understand what you are saying. Please believe me that I am not taking the company side in my explanation of this point also - I would not take the company side of anything right now.
Although your booklet is dated for 05/03 that doesn't mean that is when the actual caps and limits were put into affect. This mess directs back to the "self-funded" issue. BCBS creates a general info booklet on the coverage that the employer has chosen to offer and then sends that off to the employer for final approval. Unfortunately it is not uncommon at all for a benefit book to sit on the desk of some Human Resources VP for months at a time. We have an airline account that has still not received a book and their coverage was active as of 1/1/03. This unfortunate situation is just one of many that fall back in the lap of the illustrious crystal palace.
You do bring up one point you may want to explore, although since BCBS-US has already made payments it may be too late. In most states the law does require an insurance company to continue paying for treatments for a reasonable length of time after coverage is changed providing there are no breaks in treatment. This is all part of continuation of coverage. This would mean that if it had been diagnosed as morbid obesity which is considered and illness that:
- If treatment was constant and there was no break in that treatment for
More than 30 days and
- If United Healthcare had already given the treatment and/or surgery
Pre-certification to be done and
- If all procedures and treatments were done under United Healthcare
medical guidelines and
- If treatment was finished within 90 days of changing to a new health
insurance carrier
Then there is a good chance that United Healthcare may have been responsible for the payment to continue the treatment to completion. Health Insurance companies in general don't want you to know this and you can bet the employer does not want you to as well. In most cases the employer changes insurance carriers to lessen the financial impact on themselves. The other instance where continuation of coverage can come into play is what sounds like BCBS opted for here. That is to give the okay based on the information provided to the previous carrier for the treatment and/or surgery to be done by the doctors approved by the previous carriers in-network provider, and be treated as an in-network claim by the new carrier. The only downside to that is what happened here, and that is that while they don't require the change of doctors or additional information, they do so under the BCBS guidelines and under their payment schedule.
As stated before, you make a good argument and your points are clear. The best option in regards to this is to file your appeal and see what happens. You also have the option of an actual hearing as well. In that instance you may ask to discuss the issue with the appeals board at the insurers home office. You do have to travel there for that though, they don't come to you. Keep in mind that all these people can do is attempt to influence US Human Resources on your behalf should they agree with you after hearing and seeing your case.
Best of Luck
