Question:
Excluded-Any treatment for obesity

What do I do when the health plan book says that any treatment for obesity is not covered?? I called the insurance company prior to going to my first consult, and they said that gatric bypass surgery would be covered if nedically necessary. Now they are saying that in my husband's employer's health hand book is says, "Excluded Medical Expenses-Charges for any treatment of Obesity including diet control, diet supplements, enrollment in a health, athletic or similar club" I don't know if I should appeal or what? HELP PLEASE. Has anyone had this and still got approved??    — JANET G. (posted on April 25, 2002)

April 25, 2002
I've read elsewhere on this site that you may be able to appeal the exclusion by arguing that obesity is not the same thing as morbid obesity. Morbid obesity means just that--you could die if it isn't treated, and the only known cure for morbid obesity is WLS. You might want to read other questions and answers concerning exclusions in this site's library. Good luck!
   — Kristie B.

April 25, 2002
I don't have an answer for your question. I had my RNY 17 months ago.My husbands insurance covered the procedure 100% This year my husbands employer specifically excludes WLS- They specifically state that they will cover ANY condition caused by or made worse by morbid obesity. But they will not cover services or supplies that do so by treating th obesity directly. How stupid is THAT?????
   — Cindy K.

April 25, 2002
I spoke with a lawyer about this very thing!!! Unless it states MORBID OBESITY you have a loop hole if you have comorbid conditions. SO YES, APPEAL!!!!!!!!! Morbid Obesity is very different under the eyes of the law. Your doctor's office should be able to help you with this. (Quoting health statistics and how they apply to your case.) If the policy specifically states an exclusion for the treatment of Morbid Obesity,mentioning surgery, it is pety much "iron clad" and could hold up in court. I hope this bit of info helps. Best of luck to you!
   — Linda M.

April 25, 2002
Typically if it doesn't specifically exclude WLS then it by default covers it if "considered medically necessary". Don't feel bad, many insurance companies deny WLS the first time around. Just don't give up. You should definately appeal based upon your weight related health problems. I would highly recommend using Walter Lindstrom of obesitylaw.com if you want to hire a lawyer that knows WLS (he had it done several years ago and specializes in getting insurance approvals.) He only charged me $350 to do an appeal letter and i was approved within 3 days of him sending it to the insurance co. Don't give up.
   — Dell H.

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