Getting Past an Exclusion

Good evening, mates, I finally received my insurance packet in the mail today, only to discover that there is a WLS exclusion in the policy.  I've tried not to get my hopes up while waiting for this package to arrive, but it still hurts. My question is this - how many of you have had an exclusion in your policy, and been able to overcome it with an appeal?  I'm prepared to go to battle for this one, and will do whatever I can to make EVERY effort to get this done. I'm a realist - neither optimistic nor pessimistic about this.  I know there's an exclusion, but I also know that rules can bend and be broken, too.  I would never be able to self-pay, so that's not even an option to consider.  Insurance is my only chance.  I remain a tiny bit optimistic, hoping that there's a chance that the coverage may change for 2008 and by then I will be well on my way through a 6 month diet.  We'll see how it all goes.   Best wishes and have a safe & happy holiday weekend!

Depending on how ironclad that exclusion is, you may argue on grounds of "medical necessity". Sometimes this works. I know that my employer's policy has an exclusion that includes the words "even if medically necessary". I am on my husband's policy and they cover it. I am the HR rep at my company. Imagine how bad I feel having to tell our employees who see my results that our insurance won't cover it? You can always hope that they add the coverage at their next renewal. I know that we looked at adding it and it was very expensive. It would have driven up the premiums for everyone even though we only have a few who would qualify to use it. Our people fuss about how high their premiums are now. I can only imagine the hoopla if they had a big jump and then found out it was to add WLS coverage. I don't mean to discourage you though. Don't give up without a fight. I always say "It never hurts to ask." and "Never accept no from someone who is not authorized to say yes." Good luck sweetie!

I don't remember the ladies name, but she lived in Knoxville and took her insurance company to court and it was ruled in her favor because it would save the company more by paying for her surgery instead of all the medical bills and prescriptions they were having to fork out for her.  It was a civil court.  But she did win, the judge ordered the company to pay for her surgery.  Never give up, there's always a tomorrow.  It took me three years to have mine, and I had a lot going against me.  But you can always beat the system.  I wish you much success.   Love

Kathy & Susan, Thanks for your replies.  I understand all too well about the HR side of adding the WLS rider to benefits.  Dad and brother are HR managers and I worked in HR for years.  I understand the pros and cons of it... I just hate that we, as obese and morbidly obese, are left to suffer from it. BUT... perhaps there is a light at the end of this rainbow yet, and more visible than before.  I was re-reading my exclusion and this is what it says under Medical Expenses Not Covered: "for surgical procedures for weight reduction obesity and their complications" I don't see "medically necessary" in there... could it be that this is a standard exclusion thrown out there as discouragement for hopeful WLS patients, and if proven medically necessary I may have more of a chance?  I have a handful and a half of co-morbidites, so I know proving medical necessity is a piece of cake. If denied, I'm taking the same route you described, Kathy.  I'm supposed to be taking blood pressure medication, hormones for my PCOS, IBS medication, Glucophage and Byetta for my insulin-resistance and pre-diabetes, plus possibly cholesterol-lowerikng medication.  I'll have to be back on my CPAP machine, have another sleep study performed, and due to some ovarian problems, I have to have ultrasounds every 6 months or so, to check for regrowth of tumors.   Byetta alone costs around $650 per month total.  The ultrasounds usually run $600 or so dollars.  Factor in lab testing every 3-6 months, costs of all of the pills and dr. visits, and it would easily surpass the surgery in a year's time.  Not to mention I've been having a lot of pain in my joints and also some horrible foot pain, so I'm going to end up seeing the doctor and possibly the chiropractor for those problems, as well. I remain hopeful and I won't give up.  My seminar is this Wednesday... perhaps at that time they will have an insurance rep from the office there that can give me a bit more info on if they feel my insurance may cover it. Enjoy your holiday weekend and best wishes...