Question:
Shoul I fight this exclusion or just wait?

I reccieved this statement from my doctors office (from the insurance company) stating that they will not pay for the surgery because...[This certificate specifically excludes benefits for surgery relating to obesity an weight reduction treatment. This exlucsion section of the certificate states that, in part, "We will not pay benefits for any of the following: Charges for weight reduction treatment or programs, suction lipectomy, physical fitness programs or equipment (including health club membership fees or services) exercise thearapy or nutrional counsleing, except as stated in the Covered Medical Services section; treatment, diagnosis or supplies (including surgery) related to obesity." To me it sounds pretty ironclad, but a couple of replies indicated in others posts that they do not say morbid obesity, so I could fight it. However it does say weight reduction surgery. So what should I do? If I do an appeal, how do I write one. I already asked my Doc's office and she said that I would I have to write it on my own. So any advice will really help. Thanks. -Danielle    — d_n_lear (posted on July 17, 2004)

July 17, 2004
You can always try to fight it, but its pretty much written out there for you. Obesity/morbid obesity...you are talking semantics there in regards to their not stating it. Do you have your benefits guide, and can you find the info in there? You could appeal to your employer to add the coverage, if it is an employer sponsored plan. If the employer doesn't pick it up, then it isn't the insurance companies responsibility (or fault) to deny coverage for something they aren't being paid to cover. Good luck, Shannon
   — M. Me

July 17, 2004
My insurance had an exclusion clause, but it said unless medically necessary. This is a quote from what you wrote "except as stated in the Covered Medical Services section;" Which tells me that there may be a clause in the Covered Medical Services area that might possibly say "unless medically necessary." May of the insurance companies have this. It wouldn't hurt to check out the Covered Medical Services part of your coverage. Sometimes it's covered and they hope you won't find the loophole. Good luck. Surger 12/10/02 -110
   — Sharon L.

July 18, 2004
fight the exclusion. What have you got to lose??????
   — catleth

July 18, 2004
I agree with a previous post FIGHT FIGHT FIGHT! Go to your policy and READ READ READ Knowledge is POWER! That part that says Except as stated in the Covered Medical Services Section. Go There show them there LOOP and as far as the appeal letter Let them know that Obesity is just as much a disibility as maybe a back that needs surgery or a leg they would fix those problems This is Your WHOLE BODY!! Don't let them push You around sometime companies will do this just to see if they can! Best of Luck Shell
   — Shell G

July 18, 2004
Many people get it overturned if it does not not include the words Morbid Obesity. You might have to hire a lawyer, but if it was me I would fight it.
   — TheresaC

July 20, 2004
I just want to say thanks to all of you out there. I just called my insurance company. They are sending me my policy, which will be here in 7-10 days. In the meanwhile, I am gonig to start an appeal letter. You really gave me the confidence to fight, I was a little unsure before, but not now!!!!! *Hugs to all of you* Danielle
   — d_n_lear