Question:
Can you explain this excusion?

MY FRIEND HAS AN EXCLUSION THAT SAYSTHAT IT IS NOT COVERED UNLESS IT IS AN ORGANIC CONDITION OR CAUSE BY ORGANIC REASON. WHAT DOES THIS MEAN? I EVEN AS MY FAMILY PHYSICIAN AND HE SAYS THAT IT IS NOT SOMETHING HE HAS HEARD OF.    — LORETTA P. (posted on January 3, 2002)

January 2, 2002
Hi, this language is a new one on me, and I thought I'd heard everything! I don't know what "organic condition" means, morbid obesity involves organs, I suppose it qualifies. Or, since we humans are carbon-based life forms, we are organic and MO involves the body's inability to utilize organic compounds, it qualifies... The only thing to do is to call the insurance company and ask what they mean. Dollars to dog poop, it's a scam to avoid having to pay for WLS. Keep smilin', Margie B
   — Marjorie B.

January 2, 2002
Unfortunately, I believe that's one of those annoying exclusions like 'exogenous obesity', but not as bad. What I believe they mean by 'organic problem' is weight gain caused by a medical/physical problem, not poor eating choices or lack of exercise, etc. On the positive side, she maybe able to get around this one if she can prove she has a family history of obesity. The best thing I can recommend is for her to call the medical management department of her insurance company and ask what their criteria is for weight loss surgery and could she be approved if she can prove that she has a genetic prediliction towards obesity. Even if they say No, it doesn't hurt to try and apply because some people who thought they had ironclad exclusions have been approved, plus you can always appeal.
   — Anita N.

January 2, 2002
I'm a health care reimbursement specialist and a certified medical coder. I would take such wording to mean that the MO (if that's what we're talking about) must be the result of a physical condition...meaning they won't provide benefts for MO due to psych reasons.
   — [Anonymous]

January 3, 2002
Alot of insurance companies cover if the obesity is caused by "exogenous" or external reasons...such as overeating. Then there are those, like your friend's, who cover only if the cause of the obesity is "endogenous" or internal. Organic is a strange word to use, but I understand it to be a failure of say...her endocrine system...thyroid...things of that nature, but NOT due to poor eating habits and lack of exercise. Like the other poster noted...if your friend has a STRONG family history of obesity, then she would be likely to get around this...even without positive labs for endocrine probs...etc.
   — Karen B.

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