Question:
My insurance says theres an exclusion and will not pay is there a way around this?

My husband work for a city and they keep telling me there is an exclusion. Every time I ask for a benefit book they say their attorney is still looking over it. She tells me that it says they will not pay even if it is medically necessary. if this is true does anyone know a way around this or am I at a dead end?    — sheila C. (posted on February 11, 2003)

February 10, 2003
sounds fishy to me. They have to give you a written copy of your benefits. Ask to speak to a superior
   — Vicki L.

February 10, 2003
Often, if the insurance won't pay for the treatment of obesity, the surgeon and doctors can get it approved, based on treatment of covered co-morbidities. I can't imagine why their attorney would have the one insurance book that they have. Further, if they are THAT concerned about the legality of their coverage, then something probably isn't on the up and up. If you have the funds and the inclination, you could hire an attorney and let HIM ask for a benefit book. Even if their lawyer has it, a copy must be provided due to disclosure. Just a thought. If it were me, I would definitely speak to an attorney, at least. It doesn't seem right to pay for insurance coverage and be denied the right to see exactly what it covers.
   — cherryswitch

February 10, 2003
I just want you to know that itwas exclusion with my insurance, at first they flat out told me they would not pay. Then my surgen sent in the papers and called they told them the same thing and sent me a letter of denial. I wrote a letter of appeal and they asked for a bunch of other information and then still denied me again. I appeled again and I was approved, it took me 9 months to get the approval and a lot of writing and persistance. Please do not give up, no insurance out there want's to pay for this surgery but the bottom line is, if your doctor say's you need the surgery for health reasons and you have a history of obesity they can not deny you. best of luck to you, I know exactly how you feel. I had surgery 11/4/02 and feel like I got a second chance at life. You deserv it don't give up. God Bless.
   — Consuelo B.