Medical Mutual Insurance Trouble

I will try to make this short. I have been trying to get approved for surgery since February 2004 (almost a year now) and they kept denying me cause my BMI was not 40 over the last five years. My BMI is 39-40 with co-morb. (high blood pressure, high cholesterol, sleep apnea and heart disease these conditions are documented by my doctors). I have letter from all of my doctors stating that I need this surgery. I tried getting approval under my policy and they denied me for the BMI and also said that my co-morb were under control with medicine. So I then got on my husbands policy (same insurance, different employer) and submitted under his insurance. They (Med. Mutual) said that I had to wait six months before submitting a new claim, so now the claim under my husbands was put on hold until Dec. 30, 2004. I contacted the Ohio Dept. of Insur. and they sent Med. Mutual a letter to review my case again cause I provided them with new documentation. Well Med. Mutual reviewed all of my old information and just denied me again. My new information has been sent and they have it, but they did not review it before they just denied me. So I was told from the appeals coordinator at Med. Mutual to write an appeal letter and send along with this new information again. I know from my previous experience with them, I only have two appeals (and the last one gets sent out for an external review). I am tired of playing their games. I would like to know everyones opinion if i should just do my own appeal or hire an attorney? Please let me know what you think. Michelle

Michelle, Try and appeal it on your own first. Exhaust all your efforts befor you contact an attorney. Medical Mutual likes to play games. It wil also help if you get a strongly worded letter of support from your pcp. You can get medical mutual to overturn their decisions, I did. I had surgery on January 5th, after fighting med. mutual for almost a year. Ins. Co's want you to fight for your surgery. Good luck. stacie

HI Michelle, I sympathize with you about Medical Mutual. Read my profile and you will understand. They denied me three times and then all my doctors got together and sent a letter and also filed a complaint with the State Board. Just ask why they deny you and do what they say and they have to approve at some point. I am sure Walter Linstrum can help. I feel Insurance companies always deny and see how many people give up first. If you have any questions, please feel free to e-mail. Good Luck Richard