Question:
Denied today, will appeal. Desperate for advice, info, help, PLEASE!
I was denied because of an exclusion. here is the letter i recieved from Ins: "We have received a letter requesting Gastric Bypass Surgery with Laboratory Testing under the diagnosis code of 278.01. I am sorry but this would not be a covered expense under the plan guidelines. The Plan excludes surgical procedures for the treatment of Morbid Obesity or any complications arising therefrom to include, but not limited to Mason Shunt,Banding,Gastroplasty or intestinal bypass. Medical weight programs and counseling are not covered." Based on that is there any hope for me? What can I do? Is there ambiguous wording that i can perhaps get around? I plan on fighting them! I am piecing together an appeal, and need all the help and advice I can get on it. I desperately need this surgery; I'm 17, BMI:55, in pain constantly. The insurance is through my parents work. Please help! Thank you so much — amie (posted on July 10, 2002)
July 9, 2002
Most policies have an exclusion about the surgical treatment of obesity,
but unfortunately, your policy actually uses the words "morbid
obesity." My opinion: you're fighting a losing battle. I would
change jobs and get a new insurance plan if I were you.
— Terissa R.
July 10, 2002
Mandy, I agree with Terissa. I would probably find me another job as well
since this company was specific in addressing "Morbid Obesity" as
an exclusion. Doesn't it make you mad that people are so inconsiderate and
unconcerned about WLS? They probably wouldn't be if it involved one of
their family members. We've REALLY got to think about a NATIONWIDE PETITION
or something to the United States Congress or higher if need be about these
type of denials for ALL of us!!
— yourdivaness
July 10, 2002
Thanks to you both!!! I agree with you Hadiyah (thats a really beautiful
name, btw) this is downright unfair and will someday be illegal to deny a
person such a life saving operation, I hope. About the job, I wish I could
get one. But I can't. first being because I can not drive. I didnt even
take classes last year because i'm just too big and its too uncomfortable.
:( and unfortunately I live out in the country, in amish country actually,
so i would need to travel upwards of 30 mins to an hour to my prospective
job and i have no way of making that commute. I havent lost hope on the
appeal, i actually just found 3 people on here who beat the exclusion with
this particular insurance company.I hope i'm as lucky!!
— amie
July 10, 2002
Try www.obesitylaw.com...low priced lawyer who has been through this and is
expert at helping for a very low fee...you can email your info. and set up
phone appointment for a quote...web site says usually under $500.
— Amy S.
July 10, 2002
Read the Benefit and Coverages manual cover to cover and check to see if
there is a "medical necessity" exception.
— Tonya C.
September 5, 2002
Mandy, good luck with your battle. I wish we all could get approved with
no questions asked! I am facing the same situation with United Health
Care. Surgical treatment for obesity and morbid obesity are excluded. My
surgeon feels that it is worth a try to fight the exclusion when you break
it down into terms of money and how much it will SAVE them by paying for
it. I'm also going at it by showing them I am super morbidly obese, not
just morbidly obese! Hopefully we will both prevail and beat these
dastardly insurance companies. I think I'll start that petition on a web
site. That was a great idea Hadiyah!!! I'll get working on it.
— SMG I.
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