Question:
I have exclusions in my policy that say that my insurance will not cover ...
"any surgical procedure intended primarily for treatment of morbid obesity, including gastric bypass and jejunal bypass or complications of bypass surgery. Also, weight loss programs or clinics that utilize very low calorie supplement in any form, such as liquid or pre-packaged food and all related laboratory or diagnostic testing, vitamins or medications." What do I do about this? This is taken directly from my policy coverage on their website. I have seen that others here have gotten approved with Humana... Please help! I read that and just about started crying. How can they be so blind?? — Toni C. (posted on November 5, 2001)
November 5, 2001
You should look into your States "Mandatory Coverage" laws. Many
States have them and will force your insurance to cover you if you meet the
laws standards.
— blank first name B.
November 5, 2001
It's highly unlikely that your coverage has a wls exclusion if it
isn't legal in your state. But, do double check with your state's
insurance commission. You can still have the surgery if you can get
your employer to authorize the insurer to cover it as an "extra
contractual benefit. You ahd your docs have to convince them that having
the surgery is ultimately cheaper for them than continuing to pay for
medical expenses (present & future) that are caused by MO. All of
your
clinical documentation should support that premise. Whatever you do don't
mention "self esteem" and how you "feel". Document all
of your failed
diets. Document all of your co-morbidities. Have realistic goals and
make
sure they know that you will make the necessary lifestyle changes.
Several
people in support group had to get approval in this way....it took a lot of
work
and time. But, they persevered. Good Luck.
— [Anonymous]
November 5, 2001
Toni,I have the same exclusion in my policy although I have different
insurance. However, they approved me within 5 days.You never know. Good
luck.
— Ella P.
November 5, 2001
Hi guys! Thanks for the answers. Ella... that gives me hope :) I don't
know about going to the employer, though. I am under my mom's insurance
since I'm still in college. I'll be looking up the mandatory coverage
stuff though. Anyone know anything about Wisconsin insurance coverage?
— Toni C.
November 5, 2001
Yes, I have the same exclusion. Must be united healthcare. You need to
check your state. To make sure they don't have a law prohibiting the
insurance companies from discriminating against you for your weight. You'll
find it in there if it's there. Then you need to submitt a request, let it
get denied (don't let it bother you) then you need to request consideration
from your employer on the basis of medical necessity. There will be a
loophole in there somewhere that you can fall into for sure. If all else
fails and you still have your gallbladder (you may find out that it is bad
and needs to come out anyway.) this was the insurance will have to pay for
part of your hospital stay, anethia, and surgeon fee. They won't get off
scott free I guarentee there is a way.
— K T.
January 19, 2002
Actually, those who are saying the employer makes these exclusions are only
correct if you are on a self funded policy. Most smaller companies aren't
self funded, and therefore, do not set the plan coverages themselves.
— [Anonymous]
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