Question:
My insurance denied, but there is exclusion... What should I do next?
My insurance is United Healthcare Choice Plus, I have in and out of network benefits. I have studied the policy carefully and it clearly states that tx or surgery for Morbid obesity is not a covered benefit, but there is an exclusion if deemed medically necessary. My denial letter I recvd. from UHC, stated that "even if it may be medically necessary, my policy does not include benefits for this proceedure."(why would the policy say it will cover care if deemed medically necessary in or out of network if they are saying there are no benefits?). My PCP has signed a letter that I wrote with all my diagnosis and medication I am on and diet pills and diets that I have tried etc. He signed it and said he agreed with everything that I had written and agreed that this surgery would be beneficial for me. The question I have, is what now? what else can I do??? What do I do if they deny it a second time? I know that United Healthcare is one of the better insurances that New Start works with, so I feel like there is still hope...plus I have been praying if it is His Will, then it shall be done. I just want to be sure there is nothing else I can do to help things along. Thanks. — Marie B. (posted on July 17, 2001)
July 17, 2001
Marie--
Call United Healthcare Choice Plus and ask what the procedure to appeal the
denial is--it may be listed at the bottom of the denial letter. If your
coverage is through your employer, call your benefits department and ask if
they have any suggestions. If you've read through this site, you know
there are plenty out there who have been through what you have. Good
luck!!
— Jenny R.
July 17, 2001
I'm in the same boat right now. Every insurance policy should have an
appeal process. Your initial inquiry was denied, so you can appeal. Check
the policy (or better, call the person) and ask, politely, what you need to
do to start the appeal process. My insurance company has been helpful in
working with me to file the appeal, although they do tend to drag their
feet at times. Good luck,,,don't give up.
— Rosie P.
July 17, 2001
Hi Marie, I have read your profile also but there's no indication as to the
type of surgery you're seeking approval for. I looked for this because of
something you said in your question: that the ins co said that even if
deemed medically necessary, the policy doesn't cover benefits for this
procedure. That sounds as though it's that particular procedure which isn't
covered, but if you should chose another, it may be covered. Some ins cos
will not cover certain procedures even though WLS is covered. For example
they may cover RNY but not DS or lap band. This is just something to think
about.
— dandjon
July 17, 2001
Does anyone out there have Midlands Choice insurance and if so did they
cover your open RNY surgery. I have it and have been denied on all 3
appeals and evern had 5 drs letters sent in on the last appeal.
— Trudy M.
July 18, 2001
I hate to br the "bearer of bad news" however, I was denied 3X
the same type of thing w/ my insurance co. I appealed
2X and was in contact w/Walter who told me I would probably
not win, because they are "self-funded Govt" type of inssurance
co. I HOPE this is not your case and does not apply to you!!
I have since changedjobs and my new insurance covers.
Good Luck to you!!!
'
— [Anonymous]
July 18, 2001
I don't know why people respond as annonymous, what are you ashamed of?
What do you have to hide? I tell ya...I am standing in faith with God the
Father and believing that He Will make a way for me to have this surgery if
it is His will for me! If you are the "Bearer of Bad News" why
are you so ashamed to reveal yourself and let others look at your
profile...It seems like people that don't want there identity known tend to
always have nothing good to say to anyone.
— Marie B.
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