Help!

Hi!
I've been a part of OH for a little while now, but I have never posted... So, I suppose today is as good as any other day! LOL

I would like to find out more information regarding my insurance coverage. My policy has an exclusion for WLS, but through research I have read that you can appeal the exclusion to your insurance company if you are obese with co-morbidities. I would like to know if anyone else has had to deal with the appealing of exclusions. Any information would be a HUGE help!

http://www.stress-free-weight-loss.com/health-insurance.htm
http://www.buzzle.com/articles/lap-band-surgery-will-insuran ce-cover-the-cost.html
http://www.wlshelp.com/weight-loss-surgery-insurance.html

All 3 of those sites have info on exclusions. Maybe I'm reading too far into it... I'm not sure! I'm very confused...lol!

Thanks so much,

Emily

Gosh Emily - couldn't you post something easy for your first time?

It's my understanding excluded means nothing you can do will get the insurance to pay for it period.  The only way you can appeal the decision about the surgery normally is if the policy says it will pay for it but they tell you they've denied your request for surgery.

I hope someone else can give you some more positive input!!

Frankie

Lol - I suppose this would be considered a hard question!

The only reason I ask is because through research I have come across quite a few sites online that talk about the posibility of appealing the exclusion. Here are a few experpts from those sites I posted in my first post.

Maybe these will help everyone to see where I'm coming from LOL!

"If your insurance policy excludes weight loss treatments:

Your policy may state specifically that weight loss surgery and all it's complications are excluded from coverage. Even if your booklet says this, be sure to call the company anyway. You may be allowed file for a special exception on the basis of medical necessity. The outcome of the request will depend on the wording of the policy and any internal administrative rules and medical policies that have been developed by the insurance company. Some companies will not go outside the wording of the contract, and will not allow special exceptions.

If you are allowed to request a special exception, ask your customer service representative for the details about how to do it."


"Appealing a Weight Loss Surgery Exclusion

If your insurance plan has an exclusion for weight loss surgery, it may still be possible to get approval if you obesity co-morbidities. Insurance policies often exclude benefits for "obesity surgery" or surgery for the "treatment of obesity." The basis of the appeal would be your doctor's recommendation that lap band surgery is the best method of treatment for your life-threatening health condition, such as diabetes, high blood pressure, heart disease, or severe sleep apnea. Since these health conditions are usually covered by your insurance policy, you may succeed in getting approval for weight loss surgery as a treatment for one of these conditions."


"Appealing Insurance Plan Exclusions for Weight Loss Surgery

In addition to treating obesity, bariatric surgery is now considered an effective treatment for many metabolic diseases and conditions including type 2 diabetes, hypertension (high blood pressure), high cholesterol, obstructive sleep apnea, and non-alcoholic fatty liver disease. Even if your insurance plan has an exclusion for "obesity surgery" or "treatment of obesity" it may cover treatments for the above-mentioned health conditions. If you have any of these obesity co-morbidities, the appeal would be based on the recommendation that bariatric surgery is the best method of treatment for these listed diseases, which are usually covered health conditions."



Ok, so maybe I'm just crazy...LOL! But, hey! If this is a bit of a "loop-hole" to get past the exclusion, then I'm very interested in learning more! Haha.

Well I certainly hope the "loop-hole" works for you!!

Frankie

Haha....yeah...

I probably wouldn't be so lucky though...

Whatever...I just wanted to see if anyone had experience with this type of situation...

Apparently not. Haha...I figured this much though...It's an interesting topic though.

Thanks for the input Frankie! :)