Question:
How do you get the insurer to cover the surgery if they have a exclusion policy

I'm a little frustrated. I've had an evaluation with the doctor, and the insurance won't cover the visit, surgery, or anything involved with weight loss. They claim even though it is a chronic condititon, that it is cosmetic and my employer has it as written exclusionary policy. HELP.    — Crystalyn (posted on March 4, 2004)

March 4, 2004
It is virtually impossible to get an exclusion overturned. A very few have. Especially if it is an employer exclusion
   — Delores S.

March 4, 2004
I've heard that you can ask the your company insurance administration if their is a rider policy, which may stipulate a way to get around the exclusion.
   — Lolo

March 4, 2004
There is one state, I think Virginia, where the insurance companies can't legally exclude WLS. Or you could try a different job/insurance provider.
   — PattyL

March 4, 2004
The info about Virginia is partially true (and also holds for Maryland). If your employer is self insured in those states, there can still be a written exclusion.
   — antiques55

March 4, 2004
You can always check with a lawyer. Walter Lindstrom will let you know before he takes on a case if he thinks that he can help you. He has a great track record and I know has overturned some exclusions. He is at obesitylaw.com. Check with him and see what he thinks.
   — xena28

March 4, 2004
I would check with a lawyer also. Gary Viscio is at [email protected] and his fees are almost half of any other lawyer. He hasnt lost yet
   — superellen

March 4, 2004
Hi, I'm in the process of appealing my exclusion policy from my employer (I have five of the six co-morbidities related to obesity), and I have hired Walter Lindstrom from Obesitylaw.com. So far I have been very pleased with them, I just received my first "26-page" long letter to my insurance company, then after that another one will go to my employer and we will go from there. I figured since I can only appeal once I wanted to do what I could to help myself so I hired Walter. The firm seems very knowledgable, they have been through the surgery, understand what we are going through and will work with you for payment plans if you cannot afford payment right now. I thought they were very reasonable to help with the appeal process. if you would like to chat with me more please email me and we can exchange phone numbers. Good luck to you in your quest to be a "loser" with me! Jennifer - BMI 51, Age 47, 5'3"
   — jenniferw

March 5, 2004
I am under the impression that any policy can have any exclusion that they want, based on what your employer pays for. When I was trying to appeal my reconstructive surgery for medical necessity, the rep. from BC/BS wrote to me and said, "While we understand what you are saying and do not deny that the procedure was medically necessary, these procedures are just simply NOT a covered benefit by your employer". They went on to say that "if every insurance policy covered every single procedure that could be deemed medically necessary, no one would be able to afford the premiums of health insurance coverage". Even though it's not what we want to hear, you have to admit that it does make sense. And it's not the insurance companies fault if a claim is denied because they are just going by what the employer is paying them for. So......in a case where it is a specific exclusion, it sounds like you need to fight with the employer and not the insurance company. If the employer continues to say they aren't paying for a specific procedure, you can fight with the ins. co. all you want....they aren't going to give in UNLESS the employer decides to include that in their coverage. Good luck to you!
   — Lynette B.

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