Question:
Has anyone appealed a written insurance exclusion and won?

My insurance company just informed me that our policy states "No payment will be made for gastric bypass surgery or complications" I really need this surgery. If anyone has gotten approved after this please let me know how you did it! Thanks so much!    — Dana M. (posted on January 13, 2003)

January 13, 2003
Not that I'm aware of. It's hard to get an individual plan, especially with lots of co-morbids. Try patientfinance.com. I will be self-paying. IT'S WORTH IT TO ME. Good luck to you.
   — susan P.

January 13, 2003
For the past few weeks I have been going along and making appointments and preparing myself for my initial consultaion. Then I read this in my Group Benfit plan General Medical Exclusions "Treatment for obesity or services performed primarily for weight loss or control (including gastric bypass and gastric staplings); but this shall not exclude procedures that are necessary due to a specific condition caused by another disease. I immediately begin to freak out. I called the insurance company, (Unicare) and they were extremely helpful. They did tell me that if I was MO it may be covered, I just needed to submit the pre authorization forms to get approval. So, don't give up, read your exclusion clause carefully, and call your insurance provider and ask. They also told me that Unicare usually covers WLS, that made me a bit more optimistic!
   — S S.

January 26, 2003
I had an exclusion in my policy (UHC epo). It covered no weight loss surgery. So I went to battle. It took 15 months but I won. I sent in papers of the necessity of the surgery. My doctor wrote a letter too. I sent in 4 years of my weight charts since I had belong to TOPS and every diet that I went on. I even sent pictures of me. I had loss count on how many letters that I wrote in but it had to be about a dozen, not including the phone calls. My surgen recommend that I send them information from the NIH ( National Institute of Health) in which I did. You need to still educate the insurance company. If you still need more advice let me know. But you must not give up. That is what they want you to do. You need to contact the Plan Administrater where you work or where your husband works whoever carries the insurance policy. They are the ones who makes the rules. You will get no help contacting the insurance company direct. I even had a difficult time finding out who ours was and getting the address. Believe me I worked very hard on this and there were times I want to give up.I had my surgery Nov.26th 2002.
   — Nancy B.