Getting Past an Exclusion

Good evening, Saints, I finally received my insurance packet in the mail today, only to discover that there is a WLS exclusion in the policy. I've tried not to get my hopes up while waiting for this package to arrive, but it still hurts. My question is this - how many of you have had an exclusion in your policy, and been able to overcome it with an appeal? I'm prepared to go to battle for this one, and will do whatever I can to make EVERY effort to get this done. I'm a realist - neither optimistic nor pessimistic about this. I know there's an exclusion, but I also know that rules can bend and be broken, too. I'm laying this in Heavenly Father's hands now. I would never be able to self-pay, so that's not even an option to consider. Insurance is my only chance. I remain a tiny bit optimistic, hoping that there's a chance that the coverage may change for 2008 and by then I will be well on my way through a 6 month diet. We'll see how it all goes. Best wishes and have a safe & happy holiday weekend! :-)

Sorry Bela, I haven't checked the board for several days now. I know that most insurance companies have exclusions and people really fight hard to overcome that. People that have co-morbidities like sleep apnea, high blood pressure, diabetes, things like that have their doctor write a letter to the insurance company for them stating that this WLS is NOT cosmetic but is a life saving feature for them. With enough push sometimes the insurance companies will cover it. Good luck. This is a long hard road. Sorry I wasn't any more help. BTW - My surgeon told me that he would do my surgery and then in the end my insurance denied paying for it so my surgeon ate the cost. Good luck. Melody

Hi Melody, No worries about the response time! I can see that this board isn't quite as active as some of the other boards... and I sometimes am too tired to get on here at night. I have sleep apnea, high blood pressure, borderline high cholesterol, insulin-resistance and now pre-diabetes, Polycystic Ovarian Syndrome, Irritable Bowel Syndrome, and the beginnings of arthritis. I know that 2 of my doctors will definitely write me a letter of recommendation... I just hope it can be convincing enough. At this point, my employer still has not submitted my information to my insurance company. Our coverage is retroactive, but I would have to pay first and be reimbursed later. I don't have that kind of money at the moment, so I have to wait. Along with them not having my information, I also can't ask the insurance company about the exclusion and if WLS is allowed with comorbidities and in need of medical necessity. I pray it all goes well, but my gut keeps telling me that I'll be denied. Wow, that was wonderful of your surgeon to not pursue the costs with you! Most docs would have just turned around and came after the payment, regardless of it being their error or not. Wonderful!

Bela, make sure when your physician writes his letter to the insurance company he stresses that this is a life saving procedure and NOT cosmetic. He can then list the different co-morbidities that you have. This is a long shot but good luck. Melody

Bela, Please read your policy carefully. Some policies exclude treatment for obesity, but cover treatment for MORBID OBESITY. After much research, I decided the DS surgery was best for me, but at that time BC of Calif was claiming the DS was investigational (after they paid for thousands of DS procedures over the previous 15 years). Anyway, I ended up fighting my insurance for over 2 years, providing them with the research studies they claimed didn't exist. So the moral of the story is ... don't give up. The insurance company banks on the fact that many people, when denied, will give up and go away quietly. Best of luck with your insurance ... I believe there is also an insurance board here on OH. Laurie

Hi Laurie, My policy doesn't mention morbid obesity at all (covered or non-covered). it just states that it doesn not cover weight loss surgery or any complications related to such surgeries. When I called the insurance company, they stated that it was irregardless of whether it was deemed medically necessary or if for the treatment of morbid obesities, comorbidities, etc. I'm banking on this, and plan on using that as a loophole if I have to fight it. I'm hoping to handle this by an appeal and also contacting my HR department. But I know that what I want and what takes place can be two completely different things. I'll have to take a look at the insurance board here. For some weird reason, in my quest for knowledge here, I've overlooked that board! Thanks again and best wishes to you. Congrats on sticking with it and finally getting your surgery approved, dear! Bela