Question:
Has anybody recieved approval from an ins. co when they had a written exclusion?
I have United Health Care and my policy has a written exclusion for gastric bypass. Has anybody got around united healthcare when they had a written exclusion? Any replys would be helpful! — Kelley S. (posted on January 26, 2003)
January 26, 2003
hi kelley - i don't have the same ins. as you , but my humana ppo does have
the exclusion . i won't see the surgeon until this may , but i have made
sooo many calls to sak about this with ins. , they say if it is medically
necessary , then there is the chance it will be covered , even with the
exclusion . but i am a pessimist and expect they won't . i will wait and
let my surgeon submit for approval . i do have all the problems (co
morbids) that they say would make this medically needed . if i have a
problem with ins and the wls , then i will go to my husbands work and talk
to the pres . and v.p. about amending the exclusions , at least this once
for me .have you tried to call up your ins. and ask if there is anyway they
will cover ? if they won't for med. needed , then maybe you can talk to the
owner of the company , they are the ones who say what they want covered or
not , they can change it . good luck , i still am keeping my fingers
crossed , maybe i will learn to be optimistic if i get approved ......
— patti G.
January 26, 2003
Hi Kelly, my insurance has a pretty specific exclusion. They wouldn't even
talk to me. So,, I wrote a letter to my Human Resource person who is also
our plan administrator. She forwarded the letter to someone at BCBS. They
called me and asked for my medical records. So in a way I went in through
the back door so to speak. They told me they were reviewing my medical
records for medical necessity and to see if the surgery was "cost
effective" verses my current course of treatment ( I may be loosing my
vision in my left eye). Can you imagine? Cost effective? How can anyone
put a price on their vision! Anyway...they told me I would hear back in
about a week. That was last week so hopefully I will know something by the
end of this week. Wish me luck and pray for me. Don't give up. There are
lot's of options. Hound not only the insurance company but your employer,
too. But remember to be nice until you absolutely have to get ugly.
Ginger
— sweets1224
January 26, 2003
Hi Kelly,
I do have United Health Care--choice. Yes they will tell you they do not
approve it, but you need to have your PCP & Surgeon stand behind--all
drs. The people who man the telephones can only read to you what's in front
of them. Ask for the ph# to the appeals dept. That is who you need to work
through. I hit the same road block 11/01 b/4 I even submitted my requst for
surgery. I kept hitting the wall so I asked for appeals. The woman
(Rebecca) was great, I never had to appeal, she made sure I was approved
from the beginning. Also, if that does not work, Threaten them with a
lawyer, as soon as my friend did that in Dec., they approved him.
post op 1/24/02 185lbs.
— Pamela S.
January 26, 2003
ps...Have your surgeon include photos and also all medical problems--make
them up if you have to. Joint pain, back pain, difficulty walking,
shortness of breath, etc.. If it's already documented on PCP files--make
sure the surgeon includes that.
— Pamela S.
January 26, 2003
I have United health care, I have bbeen fighting this for almost 20 years,
not from the same insurance company but this is my latest fight..... I
waited for an answer for 3 monthes from United health care.... when the y
did get around to answering aout my claim... of course once again it is a
written exclusion... DAMN!!!! anyway, this is what I found out.....if your
policy has a written exclusion it is ecause your employer wrote that into
the policy... it has NOTHING to do with the Insurance company....which
means that
unless you go directly to your human resources and talk to them there is
nothing you can do....I have learned this from
getting denied from 4 companies with this policy.... I even tried fighting
it until a lawyer told me I don't have a case.... I wish someone cold tell
me something different....
now I am waiting for my husbands human resource department to get back to
my husband for some good news... fingers crossed...
I don't mean to put a damper on things and if you know how to get around it
Y A Y!!!! God bless you and keep trying!
— sue C.
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