SAMPLE APPEAL LETTERS
I found these by doing a Google "Weight loss surgery insurance appeal letter sample/guide" search and wanted to post it in case anyone needs help with an appeal letter or Weight Loss History. Dear Madam or Sir: I am writing to request reconsideration of the decision to deny Lap Band Surgery. The denial letter I received states that seven people reviewed my grievance letter and medical records. These seven people included: Assistant General Counsel, Medical Director of Clinical Services and Operations, Dispute Resolution Coordinator, Regional Director of Provider Network, Manager of Integrated Customer Service, Marketing Customer Advocate and a Marketing Product Development Manager. What exactly do any of these people know about the treatment of morbid obesity and what is best for me and my situation? Are any of these people bariatric specialists or even doctors? What does a Marketing Representative understand of the discrimination, humiliation and medical/emotional pain I go through every day? Do any of these people understand the tremendous difference between obesity and clinically severe morbid obesity? When a woman's BMI (Body Mass Index) exceeds 27.3 she is considered obese. Between 27-30 is moderately obese. Between 30-35 is severely obese. 35-40 and above is considered clinically severely morbidly obese. Our benefit health plan specifically states that "services or supplies in connection with treatment of obesity" will not be covered. However, three different customer service representatives read that the plan also states that "Morbid Obesity Will be Considered". If that is true, then the denial must be overturned. I am 5'6" tall and I weigh 372 pounds. That makes my Body Mass Index 60--clinically severely morbidly obese--and in need of treatment that surpasses the policy's definitions of the "treatment of obesity". With this abnormally high BMI I am at an estimated 204 percent increased risk of death at my present weight. My co-morbidities include but are not limited to: Acid Reflux Disease, Polycystic Ovary Syndrome, Hypothyroidism, Arthritis, Edema, Depression, Severe Chronic Back Pain, Numbness in Arms/Legs/Hands, Irritable Bowel Syndrome Morbid obesity interferes with almost everything I do like being able to work, doing household chores, recreation, shopping, walking, sleeping. I need to be able to get a job to help support my family but I cannot at this time. I cannot stand or walk for long periods because the back pain is too severe. I cannot drive, type, write a letter, brush my hair, do housework, or cook dinner for my family, without my hands falling asleep. I have been told this is due to a pinched nerve in my back because of my weight. I cannot sit in a regular chair for too long because my legs and feet swell up from water retention. This, I am told is due to bad circulation in my legs--because of my weight. I have dieted. Over and over again. Physicians Weight Loss Centers, Jenny Craig, Weigh****chers, NutriSystem. I have tried SlimFast, MetaboLife, Calorad and Fen/Phen. I have been on high protein diets, low fat diets, the grapefruit diet, cabbage soup diet and Richard Simmons diets. I even tried a year at the health club. The most I have ever lost at one time was 50 pounds and that was when I had mononucleosis while taking care of my toddlers (at the time). Treatment of obesity is frequently denied based upon the fact that it is specifically excluded from the member's contract. Legal review of this issue of allowing insurance companies to exclude certain types of care from the contract have been addressed in the courts and it is clearly within the prerogative of the company to withhold or limit coverage for certain types of care. The US Equal Opportunity Commission responding to complaints of widespread discrimination against obese persons has now declared obesity a protected category under the Federal Americans with Disabilities Act. The ADA is landmark civil rights legislation protecting America's 49 million citizens with disabilities against discrimination based upon that disability. The ADA broadly defines the term disability to include the following: one who has a physical or mental impairment that substantially limits one or more major life activities. Any physical or mental condition which significantly limits at least one major life activity, such as caring for oneself, eating, dressing, learning, working, walking and seeing, is covered as a disability under the ADA. There are two types of disability discrimination: a) disparate treatment, which discriminates directly and openly on the basis of the disability; or b) disparate impact, differential treatment which indirectly discriminates on persons with disabilities. "The Equal Employment Opportunity Commission (EEOC) has recently indicated that it intends to issue proposed guidelines on the application of the Americans With Disabilities Act (ADA) to various health insurance provisions. The following general principles have emerged: Equal Access to Health Benefits - It must provide the same coverage to its employees with disabilities. Employees with disabilities must be given equal access to whatever insurance or other benefit plans the employer provides. Singling Out Particular Disabilities - In contrast, however, health-related insurance distinctions that are based on disability may violate the ADA. A term or provision is "disability- based", according to the EEOC, if it singles out a particular disability(e.g., deafness, AIDS, schizophrenia), a discrete group of disabilities (e.g., cancers, muscular dystrophies, kidney diseases) or disability in general (e.g., non- coverage of all conditions that substantially limit a major life activity). The arbitrary exclusion of benefits for the appropriate medically necessary treatment of obesity in my case clearly and unequivocally violates the Americans with Disabilities Act Title III, The Department of Labor Code of Federal Regulations, The EEOC Interim Enforcement Guidelines and reasonable standards of fairness. Similar to the arbitrary and unsupported and unscientific capping of benefits for AIDs treatment that was ruled in violation of the ADA Title III the arbitrary exclusion of benefits for the surgical treatment of obesity is based upon bias and open discrimination against my disability, namely my morbid obesity. It is therefore illegal and is unjustifiable. According to the EEOC, an individual with a disability may not be subject to different terms or conditions of insurance, based on disability alone. In it's exclusion of obesity surgery from coverage as a contract exclusion, Blue Cross Blue Shield is violating the spirit and the letter of the ADA Title III. While it is permissible to create specific limitations and exclusions they may not be specifically related to the disability itself. "It is permissible under the ADA for an employer to offer an insurance policy that limits coverage for certain procedures or treatments (e.g., blood transfusions, x-rays, etc.) to a specified number per year, even if such restrictions adversely affect individuals with disabilities, so long as they are uniformly applied to all insured individuals, regardless of disabilities." In this case exclusion of the surgical treatment of obesity in the contract is obviously not uniformly applied to all individuals but is applied only to those with that disability and therefore is specifically prohibited and should be reversed. The Act specifically prohibits provisions that single out a disability for limitation. In patients with morbid obesity the recommendation for surgery as the treatment of choice is virtually unanimous. Essentially all scientific studies and medical expert review panels have recommended surgical treatment for clinically severe obesity, including all of the following: Milliman and Robertson Healthcare Management Guidelines Former U.S. Surgeon General C. Everett Koop, M.D. National Institutes of Health The National Heart, Lung, and Blood Institute Mayo Clinic Johns Hopkins University of Pennsylvania University of Texas at Houston University of Tennessee American Diabetic Association American Society for Bariatric Surgery The Cochrane Library in England The New England Journal of Medicine Robert Wood Johnson Medical School This specific exclusion is unquestionable based upon unsupported but widespread opinion that obesity is a failure of character and willpower. That is wrong. It is not at all supported by any medical literature or by anyone knowledgeable or expert in the field of the treatment of obesity. What is true is that each and every expert panel that has been brought together to look at this issue have come to the same conclusion. Given my medical conditions and weight, obesity surgery is the appropriate treatment. Therefore, in every way it can be seen that there is no legal or scientific reason for this denial. This exclusion is as inappropriate as one that might be based upon my race, gender or religious preference. I do not have a weak character. I am not lazy. I suffer from a severe medical illness that has caused my disability and I have an excellent chance of being cured by a four-night stay in the hospital. My disease is frequently lethal and denial of treatment is simply not acceptable in this case because it is obviously not based upon reasonable scientific knowledge. It appears as though it is based upon discrimination and mistaken opinion. We know that because the scientific opinion in the form of the many consensus conferences and medical literature all recommend surgery. Please give compassionate reconsideration of this before determining that my life is not worth saving. Please consider talking to my husband, my parents, my children, my friends and myself before deciding that I do not deserve an opportunity to regain reasonable health. I believe this surgery will aid me in gaining back my health, self esteem and inevitable, the rest of my life. Sincerely, Me ______________________________________________________________ To whom it may concern, My name is __________ and I am a _ year old male/female who is _foot _ inches tall and weigh ___ pounds. My body mass index is __. Therefore, I am classified as being severely obese. I am having significant adverse symptoms from my obesity. I have difficulty standing, and in doing any kind of exercise, even walking more than a short distance. I have difficulty performing any daily activities, and in participating with my family in recreation activities. I am borderline diabetic, a morbid and lethal disease. Gastric bypass has been shown to cure diabetes, and in my case would prevent the process of being a diabetic. I also suffer from high blood pressure. Essential hypertension, the progressive elevation of blood pressure, is much more common in obese persons, and could lead me to develop heart disease, damage to the blood vessels throughout the body, causing strokes, kidney damage, and hardening of the arteries. If hypertension is not under control, many complications can occur as a result of continued high blood pressure. The weight loss attained by gastric bypass surgery will cure hypertension. Also, I have high cholesterol which will eventually cause me to have atherosclerosis. Atherosclerosis causes most heart attacks. I become short of breath on any exertion. I cannot even climb one flight of stairs without stopping, and have a very difficult time performing the ordinary day-to-day duties of living, such as shopping, cleaning, and getting in and out of cars or chairs. I once was physically active, but at this time I find that I am unable to perform any recreational activities. Climbing stairs or even walking short distances makes me become short of breath. Losing weight will cure my respiratory problems. I have chronic skin problems. I am in constant battle with yeast infections and chronic rashes in folds of my body. My obesity causes these skin folds so that skin rubs on skin and the moisture trapped in those creases cause the infections and rashes. I also suffer from polycystic ovary syndrome, edema in both of my legs, menstrual problems and acid reflux because of my weight. Because of my weight I am depressed. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, and what really hurts me the most is the sneers and remarks I get from strangers in public. I cannot enjoy theater seats, cannot fit into theme park or carnival rides, or ride a bus or airliner, otherwise I cannot enjoy life to the fullest. There is no wonder, that anxiety and depression might accompany the years of suffering from the effects of a genetic condition. I suffer from depression related to obesity. Having this surgery will help me be healthy. I am only __ years old and cannot lead a young persons life because of me being morbidly obese. All of my symptoms from being obese would be cured from having gastric bypass and would let me live healthy again. I do not want the surgery just so I can look great. I need it for health reasons, as you can see. Sincerely, John Doe XXXXXX ______________________________________________________________ History of diets letter: To whom it may concern, This is a list of my dieting history. Weigh****chers, 15 years of age, August to December of 1996, 18 pounds lost Nutra System, 17 years of age, January to May of 1999, 19 pounds lost Dexatrim, 15 years of age, March to June of 1997, 14 pounds lost Dr. Atkins Diet, 19 years of age, August to October of 2000, 20 pounds lost Oriental Diet, 19 years of age, Febuary to April of 2001, 17 pounds lost Slimfast, 20 years of age, September 2001, 4 pounds lost As you can see, I can lose some weight, but then I gain it all back and more. Sincerely, John Doe XXXX ______________________________________________________________ I hope this will help some of you. If not try your own search and see what you come up with. Good luck in your appeal! Monica
Monica - Great research! I am thinking of appealing although I went and had the surgery done anyway. It is beyond frustrating that insurance companies give you lip service about wanting to prevent you from life threatening diseases, and then they refuse to pay for surgery that will cure many problems. I guess they like paying for a lifetime of treatment. Thanks again - Marjorie (8/31/04 232/209/135 goal)
Not a problem, I'm happy to help! Congrats on your surgery! Sorry I didn't think to do this sooner. They're paid to tell us no and then hope we don't fight it. I think that's crazy too...paying for a lifetime of co-morbitities instead of a solution! Great job on you loss so far!