Question:
Has anyone fought an Insurance Company sucessfuly when WLS is considered an exclusion

I have tried to do this prior when I had Cigna, then exhubby's insurance changed and it became an exlusion. Now my insurance has it listed as an exclusion. I was just wondering if it would be possilbe to change their minds if you can prove you would be saving them money in the long run? Thank you for all your help.    — ForVolsRU (posted on June 17, 2007)

June 17, 2007
I too had Cigna. It is a battle with them. I fought for 4 years and finally had to get a lawyer involved. I would check the exclusion policy. My policy stated that it had to be for medical necessity. In my case I had done every thing over the years and as my weight progressed everything else was happening i.e. high blood pressure, depression, knee and joint problems, etc. I had to find out the requirements for the medical necessity and do each and every one of them. I made sure that I kept copies of everything the insurance company was sent. They will send denial letters and specify why if you have the documentation for the denial appeal the decision. If they do what they did to me you will get another denial with a different reason. My saving grace so to speak was that I had copies of each denial and supporting documents which I eventually turned over to an attorney. It is a struggle but if you persevere it can happen. I worked with Walter and Kelly Lindstrom, Esq. out of the Obesity Law & Advocacy Center, 1392 East Palomar Str., STE. 403-233, Chula Vista, CA 91913. He specializes in denials with Cigna and I can't say enough good things about him, his wife (Kelly) and their staff. You can find them on the internet. I sent them all the copies of everything that I had and then spoke with them over the phone for everything. About 6 months later they were to have a tele-conference with the insurance company and myself. He contacted me to let me know it had been cancelled and when I asked what I needed to do now he said nothing they approved the surgery. Needless to say as soon as I got home I scheduled my surgery for the following month. You can fight them just be prepared for it to take some time. Good Luck.
   — 1968 Loser

June 18, 2007
If they are willing to treat your co- morbidities and any attempt at weight loss, you can fight it. Some need lawyers, others don't. I did some research online to fight Wellcare after they denied for wanting a full 1 year of medically supervised weight loss documented. Here are some GOVERNMENT links that might help persuade your insurance company (and or scare them) into thinking that you WILL sue and you WILL win so they might as well give in and cover! http://www.fda.gov/cdrh/pdf/P000008b.pdf http://consensus.nih.gov/1992/1992WeightLossta010html.htm http://www.michigan.gov/cis/0,1607,7-154-10555_20594_20596-82522--,00.html I also suggest googling how many cases have been won against Cigna after sueing them for excluding this surgery in their coverage. Include those links in your appeal to show them that they are fighting a losing battle and that they are putting your life at risk. Good luck!
   — crystalsno

June 18, 2007
There is nothing to fight at this point. Your employer has chosen to exclude bariatric surgeries from being covered by your insurance plan. You cannot fight an employer exclusion with the insurance company. What you can do is write your HR and rally the company to include this coverage for next year.
   — R. biles