Question:
Has anyone appeaed due to a 12month waiting period denial.
I was just wondering if anyone has ever appealed a denial due to a 12 month waiting period. I have BC/BS of GA PPO. Would I just be fighting a lost cause appealing or can it be done. I would love any suggestions and/or sample appeal letters regarding this particular denial. Thanks — mikawill (posted on May 23, 2002)
May 23, 2002
This seems to be the most common thing BlueCross/BlueShields use to deny
surgery. I am assuming they want 12 months of dr monitored diet history.
Well the legal truth is they can't legally require you to do 12 months of a
treatment that they don't pay for in order to qualify for a covered
treatment. I would recommend hiring Walter Lindstrom because he got me
approved after being denied for the exact same reason by Anthem BC/BS of
Indiana/Ohio. Good Luck.
— Dell H.
May 25, 2002
Hey Dell,
Thanks for your response. The reason they gave me was that since this was a
new policy I just had to wait 12 months. They didn't say anything about
supervised diets. Also, I hadn't had continuous coverage prior to getting
that policy. I was just wondering if anyone had success appealing this
particular situation.
— mikawill
May 25, 2002
They are telling you 12 months because of a preexisting condition clause in
your insurance. Is that right? If so I was told that if you haven't been
seen by a doctor for a specific problem within the past 12 months (or
however long your pre existing condition clause is for, some are only 6
months) that they can't consider it "pre-existing". My advise is
that if you haven't seen your physician specifically for treatment of your
weight within the past 12 months to go ahead and talk with a lawyer.
Insurance companies go to great expense and time to put all these clauses
and hoops in front of you to jump, so much better if you can find a way to
make them work for you too. Good luck!
— Shelly S.
May 27, 2002
Shelly,
Thanks for responding.The answer I got from Blue Cross was that since I had
a new policy with them and because of this "particular" procedure
I had to wait 12 months. They didn't say it was because of superivised diet
attempts, it was just the way their process works. I think that I can try
to appeal, I mean it can't hurt. Maybe if I try to explain what waiting 12
months can do to my health they could re-consider.
— mikawill
May 27, 2002
This depends. If you had other insurance prior to the BC/BS policy for a
certain period of time, they can't impose any pre-existing conditions
clauses on you, no matter what. This is part of HIPPA, a federal law which
stands for Health Insurance Portability and ? Act. If they have their own
conditions for the surgery, like a certain amount of physician supervised
weight loss, they can impose that, but if you have that now, I don't think
they can make you wait to get that while you're covered with your new
policy. You really need to contact them and get their 'rule' in writing.
— garw
May 27, 2002
Gar,
No I hadn't had coverage since January of 2001 before getting this new
policy. This is exactly what my denial letter states.
"Based on the subscriber's contract and the information you have
provided, it has been determined that prior approval cannot be granted The
above referenced contract has a 12-month pre-existing waiting period in
effect through 02-27-2003. After this waiting period has been satisfied,
you may resubmit your request for review."
— mikawill
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