Question:
Can I appeal a limited amount($5000 a lifetime)for obesity?

My insruance approved my wls(on June 14) but will only pay a one time lifetime payment of $5000.I will be responsible for any and all bills after their $5000 payment. Hopefully I won't have any complications because if I have to go back to surgery due to the wls none of it will be covered. I am willing to do anything for the wls but if I could get the insurance company to help out more it sure would be a big help. I have filed for disability due to many health problems so I am not in great financial shape.    — [Anonymous] (posted on June 2, 1999)

June 2, 1999
Hi There ... You can appeal anything you would like with an insurance company. Unfortunately, if there is a monetary limit its a bit tough to beat. The argument you may want to make is that they will be paying for far less medical care in the future. There is something you should check into as far as being afraid of "complications" and the charges that would be related to them. Wouldn't they be considered under their own diagnosis? For instance, if for some reason you needed to have your gallbladder out, it should not be listed under "obesity" ... its just a thought, but maybe one you want to look into. Good Luck, and believe me, its worth all of the fighting you may have to do. Mary Anne
   — Mary Anne M.

June 2, 1999
I don't know whether or not you can appeal the $5000 limit, but I do know that if your disability is approved, you should be eligible for medicare (after a waiting period), and in this area, medicare pays.
   — Peggy51

June 2, 1999
Yes, you can appeal it. Most insurance carriers CANNOT charge you over a certain amount per year. If this surgery exceeds that (after they pay $5,000), then they HAVE to be responsible for it. Personally, I would look up anything that you can on the exclusions and limitations, and what they can and cannot make exceptions for. Also, contact a legal representative to let you know what your rights are when dealing with your insurance company. The other thing to think about is this: Depending on the type of surgery, there may be complications later on down the road. As much as it is nice to think that it will be all better afterwards, I know of several people who went through the roux-n-y surgery who have to go back into the doctor anywhere from every 6 months to every 2 years to have either scar tissue stretched or removed. Make sure that they will pay for these things BEFORE you go in for the surgery. And good luck.
   — Molly S.

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