Denied for revision

Well, I just got back a decision on my 1st appeal from United Healthcare and I have been denied coverage.  The reason I am given is that my policy (Continental Airlines) has been changed so that it reads.....Benefits for Obesity Surgery are limited to one surgery per covered person, per lifetime, while covered under a Continental Airline Plan OR have a BMI of 40 or greater and documentation from a physician of a diagnosis of morbid obesity for a minimum of five years, have a six month MD supervised diet and have a pre-surgery psycological evaluation..... I began my quest for a revision in early 2007, at that time our policy covered revisions.  The change in policy as put in place with the start of 2008.  Since I was under Aetna at the time, I called UHC in early 2007 to find out what all I needed to do to have a revision and they gave me the list.  I then went on a supervised diet, had an EGD done, had a diet and psyc eval, changed my insurance election to UHC and waited for my plan to go into effect.  (Our insurance elections are in Oct of every year).   I am so disappointed to see that the reason that I am being denied a surgery that I desperately need is becuase my company is putting a limit on the number of times that I can be helped.  To me, that is the same as if you were to tell an Alcoholic that they can only go to rehab once....and if it doesn't work out then they are just SOL.  Isn't that discrimination against people that are obese?  Isn't obesity a disease?  Why is it any less important than treating alcoholism or drug addition?  My company coverage employees and their dependents for drug/alcohol rehabilitation as many times as necessary.  Why would obese patients be handled any differently? I am just so disgusted and frustrated and sad.  I had a VBG back i***** and it never worked.  I lost about 20 pounds initially and that was it.  I now have a BMI of 46.7.  I feel like there are so many new bariatric surgeries available now that I had hope.  And now to be told that you had your chance and you failed........... it is really depressing. Has anyone run into this problem before?  I have heard (from our benefits department) that a lot of companies are going to be adding this new language to their policies in the very near future.

Sounds like you should be approved fromt his statement. OR have a BMI of 40 or greater and documentation from a physician of a diagnosis of morbid obesity for a minimum of five years, have a six month MD supervised diet and have a pre-surgery psycological evaluation.....

Sounds like you have a case for an appeal and if it means gettin an attorney to fight for you it would be worth it ..you are absolutely correct in staying that it is discrimination.  Obese people have been and always will be discriminated against unless we fight for it .....   Good Luck and God Bless You  Cheryl

im having a revison done by my personal health insurance.....it was not covered by policy...but it was appealed as a medical necissity and APPROVED!!! i pay 356 a month for my ins...low deductables..it may be something to look into..change ins

That sounds like a great idea.  What insurance do you have? 

Hi Deb, Thanks for your advice - I think that is exactly what I need to do.  What is the name of your private insurance?  I don't know which one to pick....any suggestions? Thanks for your help, Teri

Focus on the "OR" part of their policy; don't give up.

I suggest that you contact an obesity attorney. You are unlikely to get another insurance policy based on your current co-morbidities.  You can ask, but since you've already had WLS and are obese, it's going to be a struggle. I used Walt Lindstrom.  He's the best at what he does, and it's not that expensive.  www.obesitylaw.com It could save you a lot of time and hassle.  Just a thought.

Thanks.  I think you are probably right.  I was looking at attorneys but a little confused about what to do next..... You said that you used Walt Lindstrom....did you have good results?

I am so sorry to hear your insurance company is messing you around like that. Stories like yours just boil my blood because there is no logical basis for your denial. You are so correct about obesity being a disease like alcoholism or drug abuse, but the insurance companies aren't seeing it that way yet. We do have to fight for our rights. Sometimes the cost of a full blown lawsuit might exceed the cost of self-paying for the surgery yourself, but maybe not. Sometimes just the threat of a lawsuit and a few strong phone calls from an obesity attorney are enough to get meaningful attention focused on your very legitimate and serious appeal. What I don't get is why an insurance company would require a revision candidate to have a BMI as high as that of an original WLS patient before they'll help them??? That's just ridiculous. Requiring people to have a complete relapse to their pre-surgery weight, and exacerbating all their co-morbidities makes no sense at all. But WLS is an evolving industry. 10 years ago most policies didn't even cover it at all, and because so many people are obese in this country, it's almost an epidemic and everyone who qualifies is having surgery. Nowadays, the earliest surgeries are failing and the insurance companies see the trend. They have to manage their costs and they are looking for ways to deny, deny, deny. If you can afford an attorney, or private insurance, or can self pay, I'd do it. It's worth it. Good luck and keep fighting! We're with you! Lili