Exclusions overturned?

Anyone have an exclusion overturned with their insurance, and gotten the surgery?

I was unable to get my exclusion overturned, even with an attorney. One attorney I checked with, I can't remember which one (either Gary Viscio or Walter Lindstrom) had about a 50% success rate with exclusions. It's probably worth a try if you have the money for the attorney. Consider whether that is a better option than just getting a job with a company that has insurance that covers the procedure. For me it felt worth it to try going through the appeal process first. Now I'm getting ready to start a new job at a company that is more friendly on this subject. I've talked to several people who work for this company who have had bariatric surgery. Good luck. Caryl

How did you figure out if they covered it. Did you ask at your interview if that was a benefit?

I have been going to Lap Band support group meetings with my husband at St. David's hospital in Austin. The nurse who runs the support group (and also is in charge of the Bariatric Center at St. David's) had Lap Band surgery too. I've talked to her about it and also met a woman who quit her job at Scott and White hospital and started working for St. David's in order to get RNY. I met her at the seminar the Southwest Bariatric Surgeons do. I've gone to a couple of their information seminars, as much to meet people who have had surgery and meet the surgeons as to hear about the procedures. I did not ask specifically about this at the interview. I did not want to scare off a potential employer by saying I would immediately want to take off for a big surgery. I did tell them I was specifically applying at their hospital because their benefits were better than what I have at Seton. My new boss encouraged me to go to HR and look over the benefits before accepting her offer. The nurse recruiter was nice about going over the health insurance with me. They didn't show me the actual policy booklet which would discuss exclusions, but I could have asked to see that if I had needed to. I didn't need it since I had already discussed it with current employees. I'm lucky, being a nurse. It's much easier for me to change jobs than it is for a lot of people. Caryl

When I started this journey in Feb. 2005, I had read profiles on this board that gave me a lot of hope in fighting an exclusion, especially if it is worded poorly as mine is. (No mention of surgery, just services & treatment.) I have been continually denied and have sent complaints to the State of Illinois Dept. of Insurance along with the State's Attourney General and the CEO of the insurance company. My insurance company AGREES that it is medically necessary, they just say that they do not have to cover it because I work for a small company and they do not offer coverage of bariatric surgery to small groups or individuals. They even went so far as to tell me to take my business elsewhere, our premium money means nothing to them. I have argued until I am blue in the face (and spirit) that the exclusion is poorly worded, and that I find it discriminatory that they will cover someone who works for a large comapny, but not a small employer..... I just got the reply last night from the Department of Insurance and they say that my insurance company has not broken any laws by not offering the same coverage to a small company that they offer to a large company and that I am S.O.O.L. (s**t out of luck), they will do nothing to help me. I find this completely unfair, but the state does not seem to care. I do not really have the option to find another job, as I run the family-owned business for my father-in-law. The only thing that I may be able to do is try to find a carrier that will offer this coverage to a small group and start all over again in the fall. My heart is pretty much broken at the moment, and I am sorry not to be able to give you much hope. Thanks for listening...... Dawn

I am so sorry, Dawn. Talk to your insurance broker about this. Hopefully they can find a better plan for your company for the next plan year. Caryl

Thank you Caryl. I do have my insurance broker looking into it, and she says that the only one that she has heard of offering this coverage to small groups is BCBS. They seem to be fading out coverage from what I have been reading here on the boards, so it looks like I am in for a long road of disappointment and fighting for my health. I had really hoped to be on my way to better health by now. The funny thing is (if anything at this point can be funny) that my PCP is standing behind the surgery recommendation so much that he does not really want to treat the various problems in other ways, he just says that "after surgery things will all straighten out". Again, thanks for listening, and it really does help to have others know what I am going through right now. Dawn

I haven't had any luck with my husband's insurance company. They have an exclusion saying "Any treatment whether surgical or medical for obesity or controlling weight" is excluded totally! This is the 4th carrier that they've changed to in the last 4 years. Every time we start the process over (psych eval, nutrtitionist, 4-medical necessity letters)...they decide to change again. So, now I'm back to square one and waiting till April of 2006 to see who they change to then. I figure I'll be over 400 pounds by then. I did find out that Maryland "State" law requires them to pay, but "federal" doesn't. So of course, they follow federal guidelines. Check to see what your state says. Good luck, Angel