Question:
Need Advice! Insurance denied, what is next step, any other help?

Three people have had open surgery preformed from my husbands factory. All same Insurance. We have been told from Insurance and BTC Insurance rep. that our Insurance has an exlusion clause. We don't understand how others got the Insurance to pay. They say did nothing different than us. What can we do, write, or say. Would appreciate any advice. Thank You.    — Zula P. (posted on November 4, 2004)

November 4, 2004
Sounds fishy to me...but I would point blank go to whomever had this surgery approved and ask them if they had to go through any hoops to get it done. If you are being denied and there is no other reason (such as you do not meet the qualifications) then you have reason to file a greivance with this insurance company for discrimination. Look into this NOW and ACT. Let us know what happens. My best. Lyric
   — Lyric

November 4, 2004
Sometimes the exclusionary clause says "treatment for obesity" is excluded, but "morbid obesity" is covered. If your doc submitted a diagnosis of simple Obesity, then that may be your problem. I would start by asking the insurance company for the specific reason they denied you. If they simply say it's not covered, then ask specifically what is not covered (so you can get to the obesity vs. morbid obesity issue), and ask when it stopped being covered (it's possible that the exclusion was written into the policy after the others had surgery). Just keep asking questions until you narrow down the reason, and then approach your appeal from that.
   — Vespa R.

November 5, 2004
Hi Mae. I work for a company where several people had a gastric bypass. After that, my company decided they had better put a stop to it and put an exclusion in the insurance. That may be the case in your situation. I would recommend you contact your human resources department and ask when the exclusion was started. If it was before the other people had their surgeries, the best thing you could do is find out if they used a different doc and what they did to get it approved. Many insurances require that you have a certian number of co-morbitities and you be at least 100 pounds over your ideal weight. By the way, I had United Healthcare and it was excluded as well. I changed jobs, got different insurance, and got it covered. Good luck. Krista
   — kristaz

November 5, 2004
I work for a company that had Cigna HMO I called the insurance company in 2003 and found out they covered it but only with medical neccesity and a bunch of hoops to jump through. As I am getting all they need put together. I then call them in Febuary 2004 and they say they don't cover it. I asked "since when I just asked about it a few months ago" they said "the policy changed as of 1-1-2004." That could be what happened with your husbands work. Normally they don't change rules on insurance though until the end of the year during open enrollement. Luckily this year our insurance is changing to United Health HMO and they do cover it as long as your BMI is 40 or greater so as of January 2005 I am hoping to get the ball rolling again.
   — Melinda V.

November 6, 2004
Gain all the ammunition you need during this time. While you are fighting with the insurance company go to your family doctor once a month documenting everything. Also, go to a dietician and get on some kind of steady diet that can be documented as well. Ask your D. to refer you to the dietician so they can work hand in hand. Also, overwhelm the insurance company with documentation and plot out some charts of your weight over the last several years. If you show the effort they will be much more receptive to your request. Good Luck!
   — Thomas M.