Question:
has anyone been denied coverages due to insurance exclusions for WLS?

My insurance company told me that they do not cover ANY kind of WLS. They also told me that this is a choice that my employer has made on my behalf. I am devastated about this. I had such high hopes that I could finally reach a lifelong dream and now it seems like it was all a dream.    — LORI B. (posted on October 11, 2002)

October 11, 2002
I am soooo sorry that your insurance has chosen not to cover this surgery. It just makes me so mad that they do this and can get away with it!!! Yes, unfortunately I was denied coverage for WLS because of an exclusion. I fought it, but lost. My husband's insurance is self-funded and they also elected not to cover this surgery and it didn't matter that my doctor deemed it medically necessary. It went before a "board" and it still didn't matter. They stuck by their exclusion even though it didn't address morbid obesity nor the surgery specifically. If I can be of further help, feel free to e-mail me at [email protected].
   — Mari T.

October 11, 2002
I have been fighting my insurance and the group I work for since last Dec. I also hired Walter Lindstrom (obesitylaw.com) to look through my stuff and go to bat for me. My insurance is now going to pay for it. The language in my insurance booklet was vague, so I fought them. I hear people on here all the time say don't give up. Now I am a believer. (surgery Dec. 2!!!!!!!) Pat Rose
   — Pat R.

October 11, 2002
I have worked for several insurance companies and you might want to check with your employer and see if they have what is called a "self funded plan". If your plan is self funded it means your employer basically wrote the guidelines of benefits and the insurance company only administers them. In looking at your profile, the insurance you have is probably one of these. I would question why you are unable to get a benefit booklet. By law either the insurance company or the employer must provide you with one and depending on the state, there is usually a time frame in which they have to provide it to you. Most insurance companies do have exclusions for WLS, mine included, but the exclusion ususally states if there are underlying medical problems or morbid obesity, they will consider it. I have worked with several groups like this and in some cases the employer group would request for the approval since in the long run a reduction of medical costs would be paid out for the patient and therefore, lower the employers premium. Technically speaking, if it's a self funded plan, it's the employers money paying the bills anyway, not the insurance companies funds. My suggestion would be to go to your HR person and get a copy of the benefit booklet. I hope I have helped. If you have any questions - feel free to email me. Personally, I think all plans, self funded or not should have to cover this surgery.
   — Cheryl H.

October 11, 2002
I don't have the same insurance you do, but I had a written exclusion that said nothing for weight loss was covered including surgery. (I have a copy of the exact wording in my profile) I had my PCP give me a referral to a surgeon in my network (they didn't need a reason) and then after that, I had the surgeons office submit everything for me complete with letters of necessity and my psych eval and all. A week later I was approved. Somehow, I think insurance companies are more inclined to listen directly to the doctors rather than patients.
   — Toni C.