Insurance frustration

Last year I was told by a surgeon's office that my insurance would not cover obesity surgery, so instead of fighting, I just gave up. Now I'm having acid refllux everynight and my fiance says I am snoring extremely loudly and sometimes stop breathing. The main reason I want to have surgery is because I have polycystic ovarian syndrome, a disease that makes it extremely difficult if not impossible to lose weight soley with diet and exercise. My BMI is 51.7. The following I cut and pasted out of my insurance plan documents The text in blue is new to this year's documents. Is it just me or is this confusing?:  

Exclusions:

Weight control services including surgical procedures, medical treatments, weight control/loss

programs, dietary regimens and supplements, appetite suppressants and other medications; food or

food supplements, exercise programs, exercise or other equipment; and other services and supplies

that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the

purpose of weight reduction, regardless of the existence of co-morbid conditions.

Definition:

Morbid Obesity. A Body Mass Index that is: greater than 40 kilograms per meter squared; or equal to or

greater than 35 kilograms per meter squared with a high risk co-morbid medical condition, including

significant cardiovascular disease, sleep apnea, or uncontrolled type-2 diabetes.

AETNA HEALTH INC.

(TEXAS)

WEIGHT CONTROL SERVICES EXCLUSION AMENDMENT

Contract Holder Group Agreement Effective Date: January 1, 2008

The Aetna Health Inc. Certificate is hereby amended as follows:

The following exclusions are hereby deleted from the Exclusions and Limitations section of the

Certificate:

• Surgical operations, procedures or treatment of obesity, except when pre-authorized by HMO.

• Weight reduction programs, or dietary supplements.

The Exclusions and Limitations section of the Certificate is hereby amended to add the following

exclusion(s):

• Weight control services including surgical procedures, medical treatments, weight control/loss

programs, dietary regimens and supplements, appetite suppressants and other medications; food or

food supplements, exercise programs, exercise or other equipment; and other services and supplies

that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the

purpose of weight reduction, regardless of the existence of co-morbid conditions. Has anyone else had an experience with this particular type of document? I looked at an obesity lawyer's website and they state on the website that they don't have great success with exclusions. Has anyone successfully fought an exclusion? Thank you, Maghan

Mahgan the policy does not cover weight loss surgery and the Obesity law website is correct its virtually impossible to get that overturned to pay as the contract is in black and white.  Hate to bear bad news but your have no legal recourse basically since the exclusion clearly states but you always have the right to lobby your employer to add WLS to the contract at the next open enrollment.

Employees need to educate employers about WLS the following link is a weightloss coalition group that gives very much resourceful informatio http://www.obesityaction.org/aboutus/index.php

First, exclusions have been fought and won. Second, it is hard and rare, but it is not an automatic zero and you're right to ask the question. In this case, because you're in Texas, you'd probably have no luck.  Some states like MD, CA, NY etc dont allow exclusions to stand on non self funded plans, so dont let someone's inability to overturn an exclusion guide you.    My firm has overturned exclusions, using either litigation, or even settlements.  BUT, in Texas, if your self insured your employer is allowed to exclude it, and if it's private Texas has no ability in their insurance department like those other states to overturn an exclusion. That said.  On your on.  Fight it.  Write letters.  Bug them.  Keep on them, and you never know.  I've heard of plenty of exceptions that were made for employees, so it wont hurt to give it a shot and wont cost you anything. Good luck Gary