Question:
Insurance has written exclusion

Has anyone with a written exclusion in their policy had the surgery paid for by the insurance company? My policy states no surgery for weight loss.    — KENDRA H. (posted on February 6, 2002)

February 6, 2002
Bad news...I think that you will have to fight it HARD. Even in states where ins. cos are required by law to offer the surgery, you co. can still opt not to puchase that portion of the policy. Good luck!
   — rebeccamayhew

February 7, 2002
Kendra, my insurance had the same exclusion. However, I was able to have the surgery due to other health issues...diabetes, high blood pressure, high col., hypothyroidism, and other not so serious problems. You can go that route with your insurance company. Discuss that with your doctor. That is assuming you have these types health problems. Good luck.
   — Teri P.

July 8, 2002
I have a self-funded plan offered to state of Texas employees w/the same exclusion you posted. I've been working w/the group at COMPASS, used to be IMAGES, and they've confirmed that the BCBS-TX exclusion isn't iron-clad because the medically necessary clause has worked, and they're working with me to get approval based on that. I know there are several who've tried to get past this based on a LOMN and were denied, but my case-worker lady seems confident based on the information provided by her contact at BCBSTX. See below: Dear Lynda, I spoke with Lettie at Blue Cross today and was told that they will consider this surgery if medically necessary, however as you have an HMO they will not allow you to go out of network. I noticed that you stated that you will roll over to PPO in September. I would suggest we wait until after September 1 to submit the letter of medical necessity for approval as they will certainly deny it due to being out of network. Please let me know how you would like to proceed and thanks for letting us know that they will consider this procedure. Up to now we have always been told that this was a "definite exclusion" on this policy even with medical necessity. Thanks and I look forward to hearing from you. Sheridan at Compass GOOD LUCK EVERYONE!! :)
   — Lynda L.