Question:
Overriding an exclusion

Does anybody know... if your insurance company has an exclusion regarding weight loss surgery, can a physician's decloration of the procedure being a medical necessity override an exclusion? Or is it written in stone. I just want to find out sooner rather than later if I'm getting ready to fight a pointless battle. Thanks so much in advance for your advice.    — kjoy (posted on March 15, 2006)

March 15, 2006
My insurance says obesity surgery is not covered, then on down it says it is, if medically necessary. You need to read thru their plan. And I think some will tell you that they took their denial to an attorney, and if it is deemed medically necessary, they have won the appeal. Most insurances will deny the first time and/or second time. They want to know how bad you need it and if you'll fight for it.
   — geneswife

March 15, 2006
Kristin, If your coverage has an exclusion then even a doctor's letter of medical necessity has no merit. I had FIVE letters of medical necessity, and still - nothing. It totally stinks. I ended up being a self-pay patient. It gave so much freedom getting to side-step the stupid insurance companies - I got to choose the surgery I really wanted, with the surgeon I really wanted, and the quality of life I wanted to have for the remainder of my life. Honestly, I consider that air-tight exclusion a huge blessing now - without it, I probably would have acted out of desperation rather than making a much more studied, rational choice! Be sure to contact your HR representative and ask for a hard copy of the policy. Read the fine print. Also - go to the Insurers link here on Obesity Help and look for your state, and then your particular insurance - see if anyone has had any luck fighting the insurance company you have. Blessings, dina
   — Dina McBride

March 15, 2006
Thank you everyone for your responses. Our insurance company is BC/BS; however, my fiance works for WalMart and the exclusion is written into his employee booklet... so it's not actually coming straight from the insurance company. I know BC/BS covers the surgery, but WalMart benefits says THEY don't. It's confusing to me, but I'm going to hopefully get some answers when I attend the seminar I'm registered for on the 21st. Thanks again everyone, I really appreciate it. ~Kristin
   — kjoy