Question:
I have Paramount and my employer has an exclusion and does not pay for this surgery.

Can I purchase additional insurance or appeal this in any way? If another insurance can be purchased what company do I go withi? And do I ask them if they cover the gatric by-pass surgery? thank you    — jmhall (posted on September 4, 2006)

September 4, 2006
If you have co-morbidities like hypertension, diabetes, elevated cholesterol, arthritic joints an appeal might work. You would need someone (i.e. either your PCP or an attorney ) to work with you to show the insurance company that by allowing you to have the surgery it would definately decrease their financial liability in the long run- they would need to show that with the co-morbidities you have a much great risk of costing the insurance company more money than simply paying for the surgery and reducing or eliminating the risks of the co-morbidities. There is no guarentee this will work but lets face it the insurance company is looking at their bottom line and how to increase profit for their shareholders. Hope this helps.
   — dabby

September 5, 2006
Definitely fight it! Your insurance policy should have an appeal procedure. Read it and follow the procedure to the letter. I had an exclusion in my policy, too. I decided that my health was too important to accept no for an answer. I started appealing and six months later (and about 12 letters to the appeals board) and not only did I get my coverage, but it wasn't just an exception that they made for me -- they added coverage of the procedure as a permanent change to their policy! This was a big win for me as well as everyone covered under my insurance. It is now almost six months post-op for me and I am down 110 lbs. and health-wise I have turned my clock back 20 years! This is the smartest and bravest thing I have ever done for myself and my family and I thank God everyday that I had the courage to tell them that denying my claim for benefits was simply unacceptable. It was a long, hard, emotional battle -- but I won! And by doing so I believe that I saved my own life. You can do it too! Feel free to email me at PHCatrina2 at AOL dot com, if you have any questions or I can be of further assistance. Good luck to you!
   — Catrina

September 6, 2006
Joyce, I went through this with two insurance companies. It stinks, doesn't it? I had five letters of medical necessity from various doctors/surgeons involved in my care - and my insurance company pretty much said, "Take a flying leap." We looked into all sorts of options - but talking to an attorney who specializes in fighting insurance denials was probably the most definitive point for us. We learned by talking to this gentleman that the chances of us winning were pretty much non-existent. (Others had tried and failed - repeatedly.) He was honest enough to tell us that the time I had left was better spent pursuing a self-pay surgery. So - that's what I did. I did my research. I realized that BPD/DS was the surgery that I wanted and felt confident about living the post-op lifestyle with. And I found that the surgeon I wanted was Dr. Aniceto Baltasar. Yep - I went to Spain for my surgery. For travel, surgery, and staying 19 days on the Mediterranean - I spent $15,000+ - and it was tax deductible! That was over 4 years ago. I've lost 210 lbs, a boatload of co-morbidities, and a wheelchair. It was probably the best decision I've made as an adult (well, right behind marrying my husband! - :)). So - don't give up! There are LOTS of options out there. Blessings, dina
   — Dina McBride

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