Question:
Exclusions by employer

Is it possible to get insurance to pay for WLS if the employer the insurance is through has an exclusion?I got a letter stating that based on this plan exclusion we cannot grant your request for weightloss surgery. It goes on to say If you disagree with our decision you do have the right to appeal further by writing to the appeals review board and we are required to tell you you have the right to bring a civil action under the ERIA. Would this do any good? Have any of you experienced this? Thanks for any help you can give me.    — Poeticjustice (posted on March 22, 2004)

March 22, 2004
I also had a written exclusion and there was no way they were going to overturn their decision. Mine did state that it excluded it even if medically necessary. I've heard that some people have managed to win their appeal if the medical necessity wasn't included in the exclusion. I ended up self-paying in Mexico. Good luck.
   — y0maria

March 22, 2004
I doubt it. Mine had an air-tight written exclusion, as well. Sought legal help - they said it was a waste of time and money and I should take my $$ and self-pay. I did write letters of appeal to my husband's employer, and both insurance companies that we had coverage through. No dice. I had five letters of medical necessity from five different physicians and/or surgeons. Didn't hold any weight with them at all. I was literally dying, but they wouldn't cover. So I did end up self-paying. I went to Spain for my surgery with one of the world's best bariatric surgeons - Dr. Aniceto Baltasar. Everything - surgery, travel, everything - $15,800. Best decision I ever made. I've lost 205 lbs since then - along with diabetes, hypertension, severe obstructive sleep apnea, my wheelchair, acid reflux, stress incontinence - pretty much everything that was wrong with me. I would do it again in a heartbeat. Blessings, dina
   — Dina McBride

March 23, 2004
Going through the same thing now. Appealing thru the Insurance commissoner now. Stay in tough and I will let you know what they say. [email protected]
   — Tammy P.

March 24, 2004
This lawyer has experience with exclusions. Gary J. Viscio, Esq. Resnikoff & Viscio, PC 145 Willis Avenue Mineola, New York 11501 (516) 742-5300 Fax (516) 742-8130 [email protected]
   — doodlebug

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