Company has exclusion clause. Help!!!

My PCP has recommended gastric bypass for me. So, I called Aetna last week and asked if it was covered on my plan. I was told yes, but according to my certificate of coverage, my company has an exclusion clause with states "Surgical operations, procedures or treatment of obesity." What can I do now?

It doesnt say "morbidly obese" and those are the key words you want to look for...Looks like you might be covered if you have a medical necessity.

Thank you! That's what I was hoping someone would say to me. The office I spoke with this morning told me no when I asked that very question, but she was the secretary. Forgive me, but I'm brand new to this process. How do I get them to overturn it for MORBID obesity (heck, for that matter SUPER morbid obesity... yuck...)? Will my surgeon's office (I don't have one yet) take care of that? My employer has been really helpful so far in that they seem willing to help me fight for the surgery. So that will be a plus, right?

Well, one of the first things I did back when I started (Nov 04') was get a copy of my benefits manual. You have to make sure is does not read that surgery is excluded for "morbid obesity even if it's medically necessary". I also checked with our benefits manager and was told it would be covered. The basic language in my manual reads about the same as yours but goody for me it doesnt say anything about morbid obesity. I'm not sure if you have a HMO or PPO plan but I have PPO and I just picked a surgeon, went to their seminar and had his office check the benefits of my insurance just to make sure I was covered. Believe me, they wont operate on you unless they know they will get paid so if your plan is PPO feel free to choose a surgeon and have his office help you out. If you have HMO and need a referral, then I would get on that right away...I heard it takes a little longer with the HMO plan but every insurance differs so I might be wrong on that. Either way, good luck to you. I've found this website to be sooooo helpful in my journey and I continue to learn something new everyday. Just dont give up!