exclusion on my insurance policy

Hi everyone, I am new to this board. I have Optimum Choice and contacted them concerning WLS. this is the response, According to your Evidence of Coverage (EOC), the confinement, treatment, services or supplies rendered for weight reduction or morbid obesity treatment, including surgical procedures such as gastric bypass or stapling, is not covered, as this is an exclusion to your policy. Therefore, all charges related to services rendered for this treatment would be your responsibility. Has anyone else ever ran into this problem? I heard there was a mandate in MD for insurance companies to cover WLS. I am 42, BMI 47, 270lbs, high blood pressure, high cholesterol, stress incontinence, shortness of breath, and i just has a cardiac cath and the cardiologist found i small blockage in my artery. He is the one that has suggested WLS. Any advice.

Your insurance co should have an appeal process but you would need a doctor to back you. Personally I havent been thru the process yet but I am worried about my insur covering it even tho they say it is covered (you never know). I have been looking at my options just in case. This is what I would do. Go to the seminar for the surgery anyway. (I think they are free). and schedule a visit with the doc. I would also ask them how much it will cost for the visit and if your insur co has paid for the srugery before. You might have to pay for this one but the doc will be your best advocate. I am sure they have dealt with combative insur co before. You could also take out a loan. Fees ARE negotiable so if the doc says they arent find another doc. Like I said, this is just my uninformed but well thought out opinion. Good Luck! K

I had the same problem with my dh insurance. It was small company disclosure. It was bc/bs. I was disappointed. I have a job at a biggr company, that does cover. Still waiting for approval. Bonnie R

My first insurance company told me that it was not covered. They tell you that on the phone because you are not talking to the right people. They dont know your co-morbid's and everything else. You have a bunch od paper work that your surgeon and you fill out then they send it to the insurance and that dept does the approval process. You cant go by what the reps say they can be wrong

Get a copy of you EOC Coleen.....and any riders that may have been added. I have Optimum Choice through Frederick County and we have additional riders that state that the coverage for WLS was changed and that it is covered for MO. Now, that said.... It is possible that your company (your employer) may have what is called self-funded insurance that is simply administered through Optimum Choice. Self-funded policies fall under ERISA guidelines which simply state that they can exclude whatever they want as long as the procedure is excluded to everyone. (nice, huh) The MD mandate only covers large group policies that are issued in the state of MD. (ie doesn't apply to self-funded plans because they are ERISA rather than state policies) Clear as Mud ...right....

thanks so much for the suggestion. i will contact my insurance company and request EOC and any riders. My company (General Dynamics) is definately a large group policy. The problem, I believe, is that even though GD has employees all over the world the head quarters is based in VIrginia. So even though i live in MD and my inurance is a MD company my job isn't.

all over the world sounds like it definately could be a "self funded" policy.... but even if it is a VA policy ....i thought that VA state laws on WLS were similar to MD's.

I have Optimum Choice and it covered everyting!  Dig deeper, my policy booklet said it was excluded, however there was an addendem....that stated coverage