Question:
anyone whos been denied and appealed all efforts where do you go from there?
I personally have kaiser, but I'm wondering what do you do when you've been denied and appealed all your efforts with your carrier. were the reasons for denial something that couldnt be "fixed"? — janet J. (posted on November 15, 2001)
November 15, 2001
I was denied once,with my 1st insurance co. then appealed was denied a 2nd
time. They were very adement about their "exclusion". I knew
that Aetna was a company that paid (most of the time) so I went in search
of a job that had Aetna. I got one!! and I will be having surgery on
12/12!!
If I would have stayed around more denials, attorney, etc.
It would have been 2 years and 50/60 more #s and I still may not have had
the surgery. It all depends on how desperate you are and what you're
willing to do. I am not telling you what to do but, rather my experience,
and me not wanting to waste any more time and money. I hope things work
out for you. Good Luck!
— Cindee A.
November 15, 2001
If you've done everything you can do, and your insurance company still
won't approve, CHANGE JOBS. It is totally worth it to be able to have this
life-changing surgery. Good luck to you.
— Terissa R.
November 15, 2001
If you have exhausted all of your appeal rights, you have no
recourse. They won't cover the surgery. I agree with the others.
Find a new job with health insurance that covers wls or look for
alternate ways to finance it. My boyfriend's parents took out a
second mortgage on their house to pay for his wls...he pays the mortgage
for them. It was a win/win situation because he got is wls and his mom
got a new kitchen! A support group friend sold her diamond engagement and
wedding rings...she's wearing cubic zirconia now....but she's a size 14.
— [Anonymous]
November 16, 2001
I was one who had to appeal many times over. I even went to State HMO Task
force (where I won) but it was overturned by the director of task force. I
kept appealing. Everytime I had something new developed medically I would
ask PCP to write a letter requesting wls. this went on for 2 1/2 years. I
think I counted 8 denials. I also had Walter Lindstrom helping too. but
persistence paid off. I had my surgery one week ago yesterday. My advice
would be to keep appealing until you find a job with better insurance. You
didn't say if you went all the way to the state level or not. I wouldn't
give in. I also asked PCP to do many tests to document need (which the
insurance company had to pay for), which thankfully she did and it helped
my case. Feel free to email me if you have any questions. I don't know
what state you are from, I am from Michigan, so things might work a little
different from state to state.
— Cindy M.
November 16, 2001
My BCBS (Healthselect of TX) has a rock-hard exclusion and wouldn't even
submit my predetermination to a medical review committee. The bounced it
back! They also will not even accept an appeal. I talked to Walter
Lindstrom and he said that even he has had no success with this particular
branch of BCBS and that it was pointless for him to take me on as a client
(in a nice way of course, lol.) Sooooo, I looked into my husband's
insurance and found that they cover WLS. I am paying an extra $200 a month
to have this secondary coverage, but if they will cover the surgery, it's a
deal!
— Kathie L.
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