Question:
Need Advice! Insurance denied, what is next step, any other help?
Three people have had open surgery preformed from my husbands factory. All same Insurance. We have been told from Insurance and BTC Insurance rep. that our Insurance has an exlusion clause. We don't understand how others got the Insurance to pay. They say did nothing different than us. What can we do, write, or say. Would appreciate any advice. Thank You. — Zula P. (posted on November 4, 2004)
November 4, 2004
Sounds fishy to me...but I would point blank go to whomever had this
surgery approved and ask them if they had to go through any hoops to get it
done. If you are being denied and there is no other reason (such as you do
not meet the qualifications) then you have reason to file a greivance with
this insurance company for discrimination.
Look into this NOW and ACT. Let us know what happens. My best.
Lyric
— Lyric
November 4, 2004
Sometimes the exclusionary clause says "treatment for obesity" is
excluded, but "morbid obesity" is covered. If your doc submitted
a diagnosis of simple Obesity, then that may be your problem. I would start
by asking the insurance company for the specific reason they denied you.
If they simply say it's not covered, then ask specifically what is not
covered (so you can get to the obesity vs. morbid obesity issue), and ask
when it stopped being covered (it's possible that the exclusion was written
into the policy after the others had surgery). Just keep asking questions
until you narrow down the reason, and then approach your appeal from that.
— Vespa R.
November 5, 2004
Hi Mae. I work for a company where several people had a gastric bypass.
After that, my company decided they had better put a stop to it and put an
exclusion in the insurance. That may be the case in your situation. I
would recommend you contact your human resources department and ask when
the exclusion was started. If it was before the other people had their
surgeries, the best thing you could do is find out if they used a different
doc and what they did to get it approved. Many insurances require that you
have a certian number of co-morbitities and you be at least 100 pounds over
your ideal weight. By the way, I had United Healthcare and it was excluded
as well. I changed jobs, got different insurance, and got it covered. Good
luck.
Krista
— kristaz
November 5, 2004
I work for a company that had Cigna HMO I called the insurance company in
2003 and found out they covered it but only with medical neccesity and a
bunch of hoops to jump through. As I am getting all they need put
together. I then call them in Febuary 2004 and they say they don't cover
it. I asked "since when I just asked about it a few months ago"
they said "the policy changed as of 1-1-2004." That could be
what happened with your husbands work. Normally they don't change rules on
insurance though until the end of the year during open enrollement.
Luckily this year our insurance is changing to United Health HMO and they
do cover it as long as your BMI is 40 or greater so as of January 2005 I am
hoping to get the ball rolling again.
— Melinda V.
November 6, 2004
Gain all the ammunition you need during this time. While you are fighting
with the insurance company go to your family doctor once a month
documenting everything. Also, go to a dietician and get on some kind of
steady diet that can be documented as well. Ask your D. to refer you to the
dietician so they can work hand in hand. Also, overwhelm the insurance
company with documentation and plot out some charts of your weight over the
last several years. If you show the effort they will be much more receptive
to your request. Good Luck!
— Thomas M.
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