Question:
has anyone beat an iron clad exclusion?
I am insured by Premera Blue Cross in Washington state and have a very distinct exclusion that states that I am not insured for any surgery or treatment for morbid obesity or complications due to this condition. It seems hard to beat, and I have been denied once, but I am curious if anyone has beat their insurance with an exclusion like this? I am desperate to know, and am so discouraged by the denial. I feel like I am being denied a heart bypass! Thanks to anyone who has any input and my best to all of you! We are in this together! — darci T. (posted on June 18, 2003)
June 18, 2003
Nope I had to wait 9 months to change insurance companies. Sorry!
— Haziefrog
June 18, 2003
Ahhh, the dreaded Premera Blue Cross! We too have them as our insurance
company and did all we could in attempt to get them to cover the operation.
We have the same exclusion. We went through their appeals process and
contacted lawyers, unfortunately to no avail. My husband and I desperately
needed this surgery and were fortunate enough to be able to borrow the
money from his parents. This surgery has literally saved our lives, and it
is appauling that insurance companies can deny coverage! Please check out
our profile, and email us if you have any questions or just need someone to
talk to :)
— [Deactivated Member]
June 18, 2003
Hmmmm... I wonder, especially after reading the answers already posted for
you, if your physician can help you out. What I mean is, what about gall
bladder surgery? Is it excluded?? If it isn't, I wonder if they could do
both surgeries at the same time, and bill your insurance for the surgery as
gall bladder. You may have to pay some for having both done at the same
time, but your insurance should pay the bulk of it that way. Just an idea!
Good luck!!
— Sharon M. B.
June 18, 2003
Sharon, if any Dr. billed like that then he could get tossed in jail.
— Sarah S.
June 18, 2003
Actually, Sarah, that can be done in some cases. Here's a scenario we
recently had where I work. A girl fractured her nose and needed a
septoplasty. She figured, "Hey, I always wanted to get my nose
changed, so I might as well do it nowand let the insurance company pay
for it!" We do cover a septoplasty (repair) but not the cosmetic
rhinoplasty, even though they are in the same place! So our insurance is
covering the hospital charges and physician charges for the septo, but the
member is paying the MD charges for the rhinoplasty. It's not exactly
"free" but she is paying a heck of a lot less out of pocket than
if she were to pay for the rhinoplasty completely as a separate surgery.
Given the circumstances, if the poster needed to have her gall bladder out,
that might be covered, and she then might be able to work out a deal with
the insurance company where she would be responsible for any charges
associated with the WLS, out of pocket.
— koogy
June 18, 2003
Let me add, the surgeon COULD NOT bill WLS as anything else. That is
called fraud.
— koogy
June 18, 2003
I think the other posts have been misread. I think what they are saying is
you have the other surgery, which insurance will cover along with the
anistheasia and room and the other charges with that type of surgery. The
wls would be an extra charge, but it wouldn't be as expensive since the
gallbladder surgery required all the other. So the wls would have to be
paid for out of pocket, along with the hospital stay. Gallbladder surgery
is performed as out patient now a days.
— cinchouli
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