Question:
1st Appeal w/ BC/BS Onpoint Ins. Co. Denial upheld

My Ins. plan exclusion states "Services for weight reduction programs & gastric stapling for treatment of obesity." My Lawyer did an appeal for me with what I thought was an excellent appeal letter- "The requested procedure cannot be considered a weight reduction program or gastric stapling for treatment of obesity. The plan does not exclude surgery for treatment of morbid obesity or super obesity w/ associated co-morbid states. Then went on to state The Dr. diagnosed me as MO, w/ type II Diabetes, sleep apnea, etc., also described obesity & Mo as two diff. conditions w/ MO as typically defined as being 100 pounds overweight or a BMI over 40, and that my bmi was 58, and that procedure was a med. necessity. Just recvd. letter from Ins. co. denial upheld stating gastric bypass is part of a weight loss program and is clearly excluded, anyone w/ any suggestions what I might include in my level 2 grievance?? Thanks in advance for any helpful advice    — Tom C. (posted on June 18, 2003)

June 18, 2003
Hey... man... that is so awful. Look at my insurance letter on my first profile: sharon brittain It helped people in their appeals... you have to hit them HARD with the fact that it will cost them LESS in the long run to give you this surgery because you won't be going to the doctor every other day, or taking that handfull of medications, or having them buy various medical equipment, and especially having them pay for hospitalization for psychological reasons! That got them for many people... PLUS, you need to get REALLY descriptive... make them FEEL your pain. Read my letter... email me if you want help personalizing it. It can't hurt to appeal and appeal and appeal! Also: Do you have gall bladder problems? Many people are discovering that if they have both surgeries at the same time, their insurance HAS to pay the majority of it if not all because it is because of the GALL BLADDER that you had surgery, not the obesity!
   — Sharon M. B.

January 13, 2012
I have one question. Are you male or female? There is a reason I ask...I too am covered by b/c b/s onpoint and cannot get the bariatric surgery. I am FEMALE. I know of 3 others covered by the same insurance who were granted the procedure/full coverage. THEY WERE ALL MEN. Just wondered... when I called over a year ago to onpoint I was told it was cosmetic surgery. One year later and struggling to lose on my own and now I'm just angry. Onpoint has covered some surgeries...and as far as I know they have all been men. I was told they slipped through the cracks and once granted coverage it couldn't be denied. Very upsetting. It's not cosmetic
   — moon205

January 13, 2012
I have one question. Are you male or female? There is a reason I ask...I too am covered by b/c b/s onpoint and cannot get the bariatric surgery. I am FEMALE. I know of 3 others covered by the same insurance who were granted the procedure/full coverage. THEY WERE ALL MEN. Just wondered... when I called over a year ago to onpoint I was told it was cosmetic surgery. One year later and struggling to lose on my own and now I'm just angry. Onpoint has covered some surgeries...and as far as I know they have all been men. I was told they slipped through the cracks and once granted coverage it couldn't be denied. Very upsetting. It's not cosmetic
   — moon205

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