Insurance says WLS isn't covered. Exceptions??

I contacted my insurance company (Coventry Wellpath) to find out if WLS was covered, and unfortunately, they say it is not covered.  BUT, he did say that sometimes your doctor can apply for an exception, given you meet the requirements.  Considering that I am more than 300 pounds overweight, and I have Type II Diabetes, PCOS, and hypertension, I think there may be a chance that I would meet whatever requirements those may be.  What I am wondering is, has anyone ever gotten their insurance company to make an exception to cover WLS, and how difficult was it?

Did you ask what those requirements were?  Do you meet them?  Sometimes we think its a no brainer when they have completely different decision makers.  For instance, many insurance companies do not consider PCOS when it comes to weight loss.  but often diabetes and hypertension is considered.  In a case like your insurance, they may require you to have 3 or 4 co-morbidities because they do not normally cover it.

If it is through your employer then they may have excluded it. If that is the case then there is no exception.

That's an unusual statement he made. Generally, your employer chooses whether or not to pay the necessary premium for WLS. If they choose not to, that's an exclusion and it's iron-clad.

You certainly qualify for WLS. I'd start by talking to my HR people. It may be that your insurance carrier simply administers a self-funded policy, wherein your employer can override the 'exclusion' on an individual basis. 

When Obamacare kicked in, my employer stopped offering health insurance.  We are a small company. Instead, they told us the specific company and said if we buy insurance through that specific company, then they would reimburse us 40% of the premium each month.  So, it is individual health insurance, not group insurance through the employer.

I'd suggest contacting the insurance company again to find out exactly what documentation and what issues they would need to consider an exemption. Then take that information to a potential surgeon and see if the billing office has ever dealt with a similar situation, they may be able to make suggestions.

Since they don't cover it, how do they have "requirements" that you would need to meet?  My guess is that the person you talked to was just trying to make you feel better.  Insurance policies are a contract: for a specific fee you get a certain amount of coverage... no more, and no less. Policies that cover bariatric surgery (because of the cost of surgery, follow-ups, and complications) usually cost significantly more than those that do not, and usually it is not covered in individual plans for that reason.

There are certain states (like Maryland) that mandated coverage of bariatric surgery, so you could check to see if your state is one of them, and in some states like California there is apparently a considerable amount of "wiggle room", but 90% of the time an exclusion is firm.

Lora

She is in SC. I could not find one individual policy that would cover WLS.