Question:
Am I going to have problems with this exclusion??

I got a referral from my PCP to their weight-loss clinic. I started going to see the Dr. there about 5 months ago. My insurance plan requires 6 months supervised care before they will consider surgery. Anyhow, my first visit to them was rejected because of an apparent exclusion in our policy. Every time I've went after that has been approved and I found out the first one was rejected because my PCP's referral had expired. Now that I'm almost done with my 6-mo waiting period, I want to make sure I won't be denied. My insurance says, " for or incident to reading, vocational, educational, recreational, art, dance or music therapy; weight control or excercise programs" Doesn't sound like a very strong exclusion but still..... thanks!    — Kayla W. (posted on April 3, 2006)

April 3, 2006
Hi! In my experience with health care in general and the paperwork for WLS in particular, your best be to determine whether you will have problems with your insurer is going to be the staff at the weight-loss center that deal with the insurance authorizations. They are probably familiar with your insurer and possibly even with your specific plan. Most insurances have the 6-mo. supervised diet/exercise requirement. Since you are attending a formal weight-loss center, the paperwork should be in order. The exclusion you cite above looks incomplete, so it's hard to comment on it. I would seem that if you have been approved for your visits, you should be OK, but who knows when it comes to insurance companies? You may be on better ground if you have medical issues related to the weight, especially with the decision handed down by the national center for medicare and medicaid recently. You can also call the insurer yourself, but be prepared for the run-around. Best of luck! Jeanette
   — meepgirl

May 4, 2006
Hi ! Working for a major insurance company myself, your pcp should have never given you a referral if it was not covered under your plan. As for the the other visits that were paid for, they could have been processed in error and with a future internal audit be reversed. However!!!!! The policy of supervised weight loss is just to have your pcp or a dietician weigh you in for 6 months straight while your are on a diet and record that for future records. Not for a weight loss facility. So I wish you luck, hope everything that was approved stays that way for you.
   — un4gettable