Question:
Will an appeal letter help even if there is an exclusion clause in my policy?

My policy states in my limiations and exclusions "Any surgicial procedure to reduce obesity" will appeal even work? I want to fight but don't want to keep getting slapped in the face with denials. Also if I send proof that I have lost weight on my own with dieting. Won't that just prove that I can lose weight so I don't need surgery to the insurance company? Keeping it off is the problem but do they see it that way? P.S. Thanks to all for the kind emails from my posting. You all helped raise my spirit!!    — kimmarie68 (posted on August 20, 2002)

August 20, 2002
I would check to see if it covers "medical necessity" and MORBID obesity. You want to stress that you lost the weight (which tells them you have the strength and willpower to use the tool of weight loss surgery to succeed) but that keeping it off is the problem. The National Institute of Health recognizes this and you may want to use that arguement as well. Don't give up!! If needed, contact the governing board of insurance in your area.
   — LM O.

August 20, 2002
Is the policy a group policy or an individual policy? As a Licensed Life and Health Broker in the State of Connecticut, I can honestly say that trying to get approval for a surgery that is specifically "excluded" will be tough if not impossible, especially if the policy is an individual one. Insurers write policies with specific language included for just this kind of scenerio. But, don't give up-have your PCP write a letter of Medical neccesity and then check the policy to see if drug & alcohol addiction is covered. If it is, then SCREAM discrimination and threaten to go tho the media. WIth all the publicity of the landmark lawsuit in NY - a Bronx man suing Burger King and other Fast Food Companies- they might decide to approve your surgery. The important thing is to not give up. If other addictions are covered, so should food!!
   — Elaine S.