Insurance Exclusion

I just want to scream!! Why is it the insurance company skate around these issues?? How can they get away with denying coverage when it can be proven as medically necessary by 2 doctors with co-morbities just because THEY chose to write it as an exclusion? Is there no consideration as to the health and welfare of the living person behind the request. I don't understand. What's worse is never being able to get a direct answer on how to fight it or if it can even be fought! Add onto that the fact that the "insurance company" is acting as nothing more than in an administrative capacity because the "insurance" is actually paid by the employer because they self-fund the insurance is even worse! Anyone out there have a written exclusion that reads (similar) "Medical or surgical treatment or regimen for reducing or controlling weight, including morbid obesity" AND know that the insurance is a self-insured or self-funded plan? I don't know where to go from here. I've gotten 3 different stories from 3 different people at the insurance company. Forget about talking directly to the HR department at the company because I was advised (and I quote)...you would have to, more or less, be dying before they would approve you. WHAT A HORRIBLE THING TO SAY TO ME!!! Doesn't the fact that my BMI is 57 or that I have sleep apnea or diabetes and other issues be a factor for a decision??? I don't want to start the procedure without first getting pre-authorization. My PCP can help me obtain most of the pre-surgical testings because he can refer me to have them instead of the bariatric surgeon but I'm so confused, upset and MAD as all heck about this. HELP. Rose

Hi, Sorry to hear the frustration in your post. Usually it is the employer that puts the exclusion in the contract if they are self insured. I know of people getting an exception from their employer for the surgery. Were you told that horrible comment from HR?. If not, check it out... nothing hurts with a try... Teru

Teru, you said that you know of people who have gotten an exception from the employer -- can you elaborate on this more?? do you know them? do you know how they started the procedure? any information can only help thanks always a gazillion questions to ask when it comes to fighting the insurance people

I used to work for insurance companies as a pre-auth nurse and whenever the policy had an exclusion, I would advise the member to speak to their employer's insurance person for an exception because the employer pays the bill, the insurance company just does the paperwork for self insured employers. Just remember that it's the bottom line that employers look at. It has to be presented to your employer in dollars and cents. The cost of insulin, antihypertensive meds, and any other things that cost the company money (including time off from work, hospitalizations, doctor visits, etc) vs the cost of the surgery. I would multiply by 10yrs to make your point. Hope this helps. Teru

Call, AND write a letter from you, and from your physician who is recommending this surgery, directly to the DIRECTOR of your HR department. Also, "cc" the president, or CEO, or highest ranking administrator, or Board Member of your company a copy of these letters. HR, or whoever makes the policy stipulations for your plan has the authority to amend on a case by case basis, their particular exclusions or inclusions for any part of the policy. - They can grant you approval for your case..... You can also check with your policies' particular "grievance" or "review" policy, and go that route. All in all - be a pain in their ass, and dont take no for an answer. Get your doctor involved as well, most times insurance claim review boards are staffed by physicians and nurses - appeal to the medical necessity and financial prudence of them paying once for surgery, or a lifetime of diabetes care, hypertension meds, and other very expensive long term therapies that are CURED by WLS. Good luck!!

I've been through the same stupid rat race with the insurance companies. Many different answers, no two people will give you the same answer on a given day, throwing the exclusion curve ball in whenever it's convenient. How unfortunate! I changed insurance companies during open enrollment and am now, (though I might be able to get approval) I'm actually reconsidering the surgery. If I do go ahead with the surgery, I'm sure this company will also make me jump through all the hoops. I'm sure you're mad as heck. I remember being livid. It also really ****** me off that you shoud have to beg and plead to the HR department for something medically necessary AND personal. They all make such a fuss about the HIPPA Privacy rules and regulations, but a person should not have to open their lives up to someone NOT in the medical community in order to get medical coverage for surgery. What a crock! I wish you good luck and good health throughout your process. PS, constantly reading this forum, has helped me be so conscious of my eating habits, that I've lost 32 lbs. in eight weeks. Do yourself a favor, try not to make the anxiety about getting approval for the surgery make you put on weight. Take care. Laurel

Hi Rosie - I am sorry I don't have any answers for you - but I just wanted you to know that I wish you good luck and hope that things work out for you. Keep on fighting!!! You are worth it! Take care, Sherri

I think that I am just so depressed that I just dont care. I have BCBS PPO. Innetwork/outofnetwork lack of certifcation... let them figure it out. My credit already sucks, so what are they going to do... I'll go bankrupt... atleast I'll be able to fit in a bikini! hehehehehe I already had a $40k hosp bill this summer and the insur company was so confused as to what they were supposed to pay, that I had to fax them a copy of my member book!!! What seem to be the worst companies to deal with... I switched from aetna hmo to get the surgery, then got sick with something else. thanks Kirs

Hi, I think the insurance companies automatically deny and hope people won't fight it. Some person behind a desk makes decisions on our health. I had my surgery in 2002 with no problem. I needed a revision and it was denied. I was shocked. My policy said "not medically necessary." It said an explanation was needed on why the surgery failed. So I appealed. I had to get Dr. notes from every Dr. I had seen in the past 4 years. My primary wrote two letters. Had copies of all my tests. It was alot of work. I started in January 2005 and was finally approved in July 2005. Had the revision in October 2005. If you want a copy of my appeal just email me and I will send to you. I offer it to anyone who can use it. Good luck with everything. Oh, I have Horizon NJ Plus.