Frustrated. Got Denied for WLS

Hello Everyone, I've been a member on this site since early last year. I've been going through hell since I made up my mind to get WLS in July of last year. I was interested in lap-band and finally did everything that I needed to do, got letters of medical necessity from 3 doctors, wrote one myself, got 1 year worth of medical records, sent everything to my surgeon's secretary so that she could send it to my insurance co. After waiting about 3 weeks, I finally get a call from my insurance co. (UHC) telling me that I've been denied due to an exclusion in my policy. I'm so frustrated and sad, because I really was looking forward to getting this surgery and finally starting my journey to being a happier, healthier person. Now, I don't know what to do. Any advice or suggestions would be greatly appreciated!!! Thanks!

Hi there! I can tell you that I feel your pain. I have been working on this since January of '05. My first policy had an exclusion and I fought all the way to the Attorney General's office, only to be told in the end that they exclusion held up. At the end of the year, we changed insurance to BCBS of IL because the DO cover this surgery, but their restrictions are severe, and I am now in the 7th month of the 12 month diet. On the other hand, I have read a lot of good things about UHC, and if this is your first denial, appeal, appeal, appeal!!! Your surgeon's office should be able to help you with an appeal. Some companies ALWAYS deny the first request, but approve after appeal if you can prove medical necessity. They figure that a certain percentage of people will take that first "no" and give up. Check out the Insurance board for this state and look at UHC (United Heath Care????) and see what other's experience has been. Keep fighting for what you know is right!!!! Best of luck to you! Dawn

Hi Dawn, Thank you so much for your response and advice. I am having so many issues trying to get a copy of my insurance policy from my job. They act like they have no clue what I'm talking about or they keep referring me to the benefit summary, which doesn't tell me the exclusions. I've heard lots of good things about UHC also. But I guess that I was an exception. Thanks again for your advice. Tiffany

What does your exclusion say? Does it say that it is excluded unless it is medically necessary? Or does it just say it is excluded? Dena

we are kinda in the same boat. I think Im gonna self pay,,, after I appeal. Before you say you cant afford it,, let me say this...... I cant either. LOL But,, then I asked myself "Can I afford NOT to?" My fat ass is 380lbs,,, bmi of 52. I can save money, but truth be told, my wife and kids will end up using it to bury me. Steve

Remember the high school track where they ran around jumping hurdles? Unfortunately, you have to think of it this way. "No" just means OK, here is hurdle one, what did I do to get here and what do I need to do to get to hurdle two. What I mean by this is the insurance company hopes when they say no you will go away. Nothing lost for them. 1. Demand a written denial letter to understand what they rely on to deny your claim. At least they have narrowed it down for you to certain items you need to meet or prove to them you qualifty. 2. Search the internet for similar exclusions to see what help you can find. 3. Post the denail online here and let us tear it apart. 4. Long before I would give up or even thin of paying for on my own, contact the obesity law center and see if the attorney's think they can help. I understand their fee is under $500 and has a 90% success rate but don't quote me on the costs. They also have helpful insurance info that is a must read. 5. Makes a difference on which coverage you are going after as well and if you have self-pay insurance, covered through a employer or relatives employer or medicare. 6. Don't give up on insureance until an attorney cannot help and or you exhaust all appeals and there is generally several levels. Jim