Question:
HELP! Is there any way around THIS exclusion? It says....
My policy reads under exclusions: "Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Specifically excluded are charges for bariatric surgery, including but not limited to, gastric bypass, stapling and intestinal bypass, and lap band surgery, including reversals. Medically Necessary charges for non-surgical Morbid Obesity will be covered." Unless I'm reading it wrong, it doesn't say exactly say it excludes surgical treatment for Morbid Obesity does it? It just says that "Medically Necessary charges for non-surgical Morbid Obesity will be covered". What's your advice on how to appeal this? What could I say in a letter? — Danielle S. (posted on May 20, 2004)
May 20, 2004
Danielle,
Sorry - but it looks pretty plain to me that it *IS* excluding coverage for
surgery. You could try contacting one of the attorneys that works with
trying to get these things overturned. www.obesitylawyer.com and
www.obesitylaw.com are two web sites you can check out. Also, there's
always the option of self-paying. That's what I ended up having to do. I
went to Spain for my surgery - and everything all tolled was $15,800.
Let me know if I can help, okay?
Blessings,
dina
— Dina McBride
May 20, 2004
It looks pretty iron clad, they used the word Obesity and named the
surgeries. I am not expert of course but it looks like it is pretty firm.
Good luck!
— TheresaC
May 20, 2004
The surgical exclusion is listed under obesity. Then they make a
differentiation in the last sentence between obesity and morbid obesity.
Right? Am I just grasping at straws? I technically have not been turned
down yet(haven't heard back), but I know it's coming and I want to be ready
for it when it does!
— Danielle S.
May 20, 2004
One more thing, it doesn't say medically necessary charges for SURGICAL
TREATMENT OF MORBID obesity will NOT be covered.
It just says that "Medically Necessary charges for non-surgical Morbid
Obesity WILL be covered"
The surgeries listed are all listed under obesity. NOT morbid obesity.
Is this a loophole?
— Danielle S.
May 21, 2004
Have yu specificall been denied? If so, you would be better off addressing
the specific reason for denial that they mail you. If you haven't been
denied, the I would make sure my submission SPECIFICALLY stated that the
proceedure/treatment was for MORDIB OBESITY, or SUPER MORBID OBESITY
(depending onwhat's apropriate for you.) They do not specifically say for
MORDIB OR SUPER MORBID OBESITY surgery is not covered, and THAT's your
loophole. Be sure all your paperwork and letters of recommendations don't
simply state obesity- get those words in there morbid or super morbid.
Good luck to you.
— LMCLILLY
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