Exclusion/Approval?

I am curious, has anyone ever been able to overturn an exclusion?  I have to wonder if it is at all possible, and if so what was the basis of the approval?  Medical necessity, or anything else such as represenatation of coverage by the insurer? Thanks, Rebecca

It has happened but it is the exception not the rule.  It usually depends on the type of coverage, self funded or not, and whether they are willing to work out a settlement with you.  That's pretty much how we've been able to do it, settlements.

The reason I am asking is that I have an exclusion on my policy and am in the process of appealing it.  My first appeal was based on medical necessity, but was denied.  Now I have a grievence review  scheduled for July 5 with a telephonic conference.  I am basing this review/2nd appeal on the fact that I have documentation of multiple instances in which UHC had assured myself and my surgeons office that wls was a covered benefit under my plan.  I have done a lot of research on my plan and the insurance laws in MO.  My plan is fully funded therefore it falls under state law.  I have even been in contact with the state insurance commission and they have told me that I have enough documentation to file a grievence with them.  I had hoped to find links to more case studies in which the insurance had been ordered to uphold their representations of coverage to its members.   Thanks, Rebecca

Rebecca, I just read your post... I too just posted a very similar post. I too have UHC and was told surgery was covered and later found out about an exclusion. This seems insane to me. Im curious to see how your appeal turned out today. Im from NY so not around you but hopefully things will work out for you! Let me know! Nicole