Question:
My husband's health insurance has the following exclusion:
"No payment will be made under this Plan for expenses incurred by an employee or a dependent:For charges for the treatment of obesity, weight reduction or dietetic control". BUT, a covered expense:"A Covered Expense shall mean a service or supply which is provided to a Covered Person, and which service or supply is: 2)Recommended by a physician; and 3)Medically necessary for the care and treatment of a covered illness or injury of a covered person; and 4) Provided by a Health Care Provider of these services or supplies". Based on this, do I have any chance of being approved for WLS? — Mari T. (posted on April 6, 2002)
April 5, 2002
Hi! Mari. I live in GA, and have BCBS Blue Choice HMO. The exclusion in my
policy reads almost the same. Notice it says obesity, that diagnosis code
is 278.00, it doesn't say morbid obesity, diagnosis code 278.01. To me that
is a good indication, along with what is written under Covered Expenses. I
called my insurance company and told them I had talked to my PCP about
having gastric bypass surgery and I wanted to know if my policy would cover
it. I was told that if it was medically necessary, it would be covered. I
feel that if your PCP feels this surgery will benefit and feels that it is
medically necessary, he/she would gladly write you a strong letter of
medical necessity. It would also work to your advantage to stay inside your
Provider network, seeking a surgeon within it (let me stress here if upon
investigation of surgeons in your area you find no one you feel as
adequate, call insurance company about your fears, see if they will approve
a surgeon out of their network). It seems to me you stand a good chance,
but you won't know for sure until you make that first call. Remember, also,
to keep good records of who you spoke to, what date you spoke to them as
well as the time of day. I'm in the middle of my insurance voodoo dance,
but it looks very promising. I know the dread, and anxiousness about
calling the insurance company. But we have so much dread and anxiousness to
deal with because of our obesity, yet there are times we must deal with it
and this is one of the times, but this time it's for you and you alone. A
chance to do something wonderful and beautiful for yourself, how long has
it been since you've made yourself your number one priority. I'm sure your
a loving, caring, compassionate person to those you care for, please be
strong and do the same for yourself, be ruthless if necessary, but don't
ever give up fighting for your good health and emotional well being.
Jo-Dee Hortz
— tinyjo
April 5, 2002
I feel sure your insurance will pay if medically nec. My had almost this
same statement and I got approved after some stuff from physician and some
tests proving that it was med. nec. I would proceed if I were you it was
worth it in my case and if they deny it you can appeal with pointing out
the med nec. Diane H.
— diane H.
April 6, 2002
Speak to your health insurance company. I just went through the same
thing. MORBID OBESITY is different from OBESITY. Although to the average
person we don't think of a difference in medical and insurance terms they
are. My insurance does not cover for obesity but did cover for Morbid
Obesity
— Diane Rhoads
April 7, 2002
I am a claims examiner and one of my jobs is to interpret plan language.
In your case it reads like the diagnosis of obesity whether it be medically
indicated (morbid) or not is specifically excluded under the plan. BUT
every company is different, it doesn't hurt to fight.
— Ronda E.
April 8, 2002
I would think that that was covered, it sounds like it,,,althought, my
insurece stated that morbid obesity was covered,,,and then i was denied
twice,becasue, i did not have enough problems being morbidly obese,and
becasue the surgery was not the norm for handling obesity,really,,so, had
the band done in mexico out of my own pocket,,good luck to you (band done
jsut over 2 weeks ago, down 11 pounds)
— amy T.
April 8, 2002
At least give it a try. What do you have to loose? except a lot of weight.
Acording to Walter Lindstrom at obesitylaw.com, if a policy does not
specifically exclude surgery for morbid obesity, especially when there are
serious weight related health problems, then legally it may have to cover
it because morbid obesity is a different diagnosis that just obesity and
that you are also treating the weight caused health problems, not just
trying to loose weight.
I would recommend, especially if you have any weight related health
problems to contact them at obesitylaw.com. They helped me get approved and
the cost was less than $400.
— Dell H.
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