insurance

Did anyone's insurance company have an exclusion, but still got approved?

I know my Cigna policy last year stated that it did not cover any treatment of obesity surgical or non-surgical, including severe obesity. It had like a paragraph, from what I saw on here it seemed ironclad. I wasn't worried because I already had WLS. Then I went to see a WLS for follow-up and hernia repair. He mentioned a revision I told him I had Cigna and it had an exclusion, but when his insurance person called in they told her it would be covered as long as it was medically neccessary. I asked my HR person about it and she said all exclusion are overturned on medical nessecity. And not that I had a medical reason like staple line disruption or anything...just to lose more weight. They said I needed to show weight lose attempts, etc. But my insurance changed at the beginning of the year so I am going through approval with a new carrier now. So don't trust what you read...and actually don't call yourself, because that person is just reading what you read. Your doctor's office talks to someone different. Hopefully, you can find an office that has a dedicated person who will check for you. And not just turn you away as soon as they see your coverage. Maybe have your PCP office check for you. Sarah

A website that you may find helpful with regards to insurance issue is: www.obesityaction.org Hope it helps! ~ Monica

Amanda- Another thing to keep in mind is that you are looking for medically necessary surgical treatment for Morbid obesity NOT treatment for weight loss. Most insurance plans have exclusions for weight loss programs. Weight loss programs are for getting rid of that 5-10 or 20 extra pounds it is very different from morbid obesity. All that being said however, many (if not most) exclusions are iron clad and air tight. Sometimes you have some wiggle room if it is a self funded policy and your employer can dictate the terms. But you do not know until you try. I believe it is always worth it to make the request and then appeal a denial, provided you find a surgeon that is willing to work with you on the submissions. Red

I lot depends on the type of insurance you have (HMO, PPO, self-funded, fully-funded, etc.). For the most part, I think that exclusions are difficult to overturn unless you have a clause for medical necessity. If you have an HMO (fully-funded) you can contact the Florida Subscriber Assistance Panel to find out for sure. Here is a link to their FAQ and contact information - http://www.fdhc.state.fl.us/MCHQ/Consumer/SPSAP/faq.shtml Good Luck, Jim