Attention Attorneys!!!

Hi all, I am in the process of a second appeal with my insurance. In my last denial from the insurance, they stated "For a BMI less than 40, our INTERNAL GUIDELINE required 'LETHAL' co-morbidities." This 'Internal Guideline' differs from my Employee Certificate of Insurance and their policy used to determine the medical necessity of surgical treatment for morbid obesity (I downloaded this policy directly from my insurance website). According to my Employee Certificate of Insurance, my policy excludes "Any charges for surgical operations for the correction of obesity UNLESS the obesity is associated with one or more current LIFE-THREATENING (according to online sources such as [www.] medical-dictionary.com, 'LETHAL' is defined as "fatal, deadly" and 'LIFE-THREATENING' is defined as "serious, severe, dangerous" -- my opinion is that they are NOT the one in the same) co-morbidities and the surgery is determined [by my insurance] to be Medically Necessary to preserve the life or health of the member." Furthermore, the word 'LETHAL' is never used in my Certificate of Insurance OR the policy used to determine surgical treatment for obesity when referring to co-morbid conditions. Additionally, NEITHER document state that co-morbidities are required to be 'lethal' in nature. It appears as if this 'Internal Guideline' my insurance uses is like a different set of rules they get to play by. Is my insurance legally allowed to do this? Today, I wrote to the Pennsylvania Department of Insurance to ask this, but wanted to ask on this forum as well. I'll be really anxious to hear what they say.... Thanks in advance, Kelly

I also wanted to add that my co-morbid conditions are as follows: Arthritis (lumbar) - Considered a co-morbidity under my insurance's policy for surgical treatment of morbid obesity. Respiratory Disease (Asthma) & Hypothyroidism - In addition to Degenerative Arthritis, these are also listed as co-morbidities on my insurance's "Precertification Requirements" form for Gastric Bypass. Thanks again, Kelly

Woohoo....I was able to solve this issue on my own through research on the internet. Kelly

UPDATE -- UPDATE -- UPDATE I was emailed by the Pennsylvania Dept. of Insurance. The person I emailed is fowarding my complaint to the Bureau of Consumer Affairs. I will soon be contacted. WOO HOO!!!!!!!!!!!!!! Kelly

I wish you the best of luck in any appeal. It took me 23 weeks but I finally went to the Office of Financial & Insurance Services in MI and I now have an order stating that Health Alliance Plan shall pay my expenses!

Hi Rhonda! That's great!! I am really glad for you!! Thanks for the luck -- I am needing all I can get! Good luck to you as well! Kelly

Rhonda! Congrats! What a story. I am inspired by your dedication to your cause. I know right where you are and how you feel. Please let us know how the first visit goes. Also, I have a psysiatric apt scheduled. What kinds of things are you asked?