A bit down

Hi everyone, I just wanted to vent a little and maybe get some advice. I'm really close to giving up right now. This wait is killing me. It's been one month since I submitted my appeal letter for review, due to the exclusion in my policy and I haven't heard a word. I call every monday only to get "if not this week, then by Monday for sure".. right.. it's been 3 Mondays now. I find it really unprofessional that it's taken them a month to do absolutely nothing. I'm done with everything but preop testing, even had a tentative date of 4/30 if insurance went through.. that's out the window. How long should I be waiting?? Why would it take them so long? The only excuse I've gotten is "it's got to go through the higher ups", which gives me a wee bit of hope, reasoning that if they were going to flat out say no, they would have done that by now.. I'd hope. Anyhow.. I'm just feeling down. Pretty frustrated. I've been really good about being patient and didn't get teary eyed until today.My stomach is in knots, I'm on the verge of anxious. I'm thinking that if I just give up now I won't have to worry about this at all and one day my ship will come again and it will be a breeze. I just sucks seeing so many insurances paying for this surgery.. if medically necessary.. all by my stinkin' one. Sorry to rant so much.. but it feeels better. Take care, Michelle

Hi Michelle: We've all been where you are! I know it's hard, frustrating etc. I feel bad for you...but, in the end it's all worth it! bonnie

Michelle, I am sorry you have to go thru this. I hope it works out for you! Hang in there! Anne Pre-op

Hi Michelle, I feel sooooo badly for you. That is terrible!!! First I must ask you which surgery you are trying to have. I know that Dr. Valin does the band and lots of insurances won't pay for that anymore. If that is the case you might consider switching to the RNY which I know he also does. Just a thought. I will be keeping my fingers and toes crossed for you. I hope you hear very very soon!! Linda

Michelle, Try to hang in there. I know the waiting is difficult, but it will so be worth the wait if you can hang in. Keep being persistant with the insurance company. I can totally relate to the anxious feelings. Rant any time you need to, Maggie

I'm pretty sure that by law they have a certain amount of time to respond to your appeal. You should find out what that time frame is. It will be written in your benefit book. You know, not all exclusions are iron clad. If you feel like looking up the exclusion and posting the verbiage here, maybe I can give you some thoughts. Do you have letters of medical necessity in order from your PCP and the surgeon? Do you have co-morbidities that they have been made aware of? Did you write a personal letter with your appeal stating how your weight negatively effects your life work and health? Did you send any photos? There is actually a LOT that you can do, I could go on and on, but really what you need to do is take the process into your own hands and not count on the Dr. submitting what is necessary. They may not be thorough enough. And, you only have so many appeals before you're out of luck. I'm sorry you're experiencing this. But if you feel like it, post some more details and we can see if anyone has any specific thoughts on a course of action for you. Alos please post what health insurance company you have, perhaps there is someone out there that has the same and can help too best, Lisa C

Thanks for the responses. This all started when I found out I had an exlusion in my policy for any kind of obesity related care, including gastric bypass surgery. I sent them 2 psych evals, 2 nutrition evals, the letter from Dr. Valin explaining why I need the surgery, a letter from my PCP and a 3 page letter from myself explaining my condition and why I need the surgery. My PCP did specifically make a point to let them know it was a medical necessity. I came prepared and I guess that's what's bothering me.. they've got the facts. Anyhow.. thanks again. I guess I'll wait "til Monday" again. Take care, Michelle

OK. Well, your comments make me immediately think of this... there is a difference between not allowing treatment for obesity and not allowing treatment for MORBID obesity. It sounds like that is a horse you need to beat to death (if you'll pardon the expression!) with the ins. company. Obesity and MORBID OBESITY are not the same thing. If your clause literally states only obesity treatments are excluded, then morbid obesity treatments are up for grabs. Just a thought. It's all about technicalities with the insurance comapny. You have to think like a lawyer and find the arguable points.

Sorry to hear about what your going through. I guess this is the price that we have to pay to have this surgery done. I work for a health insurance company and know an exclusion is an exclusion. If you keep getting denied use your appeal rights. DON'T GIVE UP BECAUSE YOU ARE WORTH IT!!!! Gina

This is not going to seem any better for you, but if you have a specific exclusion in your insurance policy, it does not look terrible favorable to you. The best that you can hope for is that there is a reasonable payback to the insurance company which you can document to prove that it will be less expensive for them to provide the surgery than not. I hope that your wait proves worthwhile. Peter