Question:
Any suggestions on what I should do now?

I've applied for Lap. RNY, and I received my first denial letter from my primary insurance company (3 Rivers who uses Midlands Choice). They denied me because of an exclusion under general limitations stating: "no payment will be made under any benefit of this plan for expense incurred in connection with: (16) charges for treatment of obesity,weight control, nicotine addiction..." The letter I received just says" after reviewing the letter and the plan document it has been determined that the surgery would not be a covered expense." When I called the insurance company prior to going to the surgeon they said that it would be covered as long as it wasn't cosmetic. Well, it doesn't say it's for cosmetic purposes in the letter that was sent. It does talk about my having morbid obesity, and the request was coded as such as far as I can tell. It seems they just ignored the fact that is a difference between morbid and obesity. They listed my history for weight loss, my co-morbids, my pcp's recommendation, everything. So, I don't understand. I asked if I could file an appeal, and they said yes, but didn't give me any instructions as to any specific forms needed or anything of that nature. They said I can send a personal letter addressed to: "Melanie". I am so depressed about this. I know that other people have been waiting much longer than I have, but when I talked to the insurance company the first time, I thought for sure I wouldn't have any problems. The surgeon's office has also sent the letter to my secondary insurance carrier (my husband's) which is Aetna. The surgeon's office said they've had problems with them too. But, she also said that she didn't understand the denial letter from 3 Rivers, because she's received letters from them stating that they had changed their policy and they will cover it (for other people, not me). The other thing I've noticed is that people stress the difference between obesity and morbid obesity. So, I'm wondering if I might have a chance in that case. Does anyone have any experiance in writing an appeal letter in a case similar to mine? If you can offer any advice, or sample letters of that nature, it would be soooo greatly appreciated. Thanks. - Autumn    — autumn F. (posted on October 22, 2002)

October 22, 2002
I sent you an email. I also have 3 Rivers Benefit/Midlands Choice in Sioux City. Don't give up. I didn't and had surgery in July 02.
   — Becky M.