Question:
Has anyone won a wls denial with a written exclusion in the ins. plan?

My husband and I both medically qualify for wls. We have gone thru all of the pre-op formalities. Even our insurance rep was positive up until two weeks ago, she stated that things looked positive and we should here something within two weeks. Then things went sour. My employer has a written exclusion in their insurance policy stating no wls or any wls procedures or treatment is covered by their plan. So, here we are in need of surgery without the funds take care of this on our own without an insurance company to back us up. Has anyone won this type of situation?    — Carmen W. (posted on January 9, 2005)

January 9, 2005
Is your company self-insured? If they are, go to the HR people and see if they will make an exception for you. I tried for 3 years to get my employer to remove the exclusion. They would not do it, so I will self pay. It was a very frustrating fight. Try reasoning with your employer and get letters of medical necessity from you doctors. Fight until you just can't fight anymore. If your employer is not self insured, fight your insurance company. I hope the best for you and your husband.
   — Terry Lynn W.

January 10, 2005
Hi Carmen, I went through insurance denial with two companies, actually. Both times because of a written exclusion for any treatment relating to weight. I.e., you could be anorexic and dying, or MO and dying - still, they wouldn't pay penny one. Didn't matter that I had 5 letters of necessity from my medical team. There was even a statement in the fine print about how it didn't matter that you were dying - it wasn't their responsibility due to the exclusion. Stinks, huh?! I did consult with Walter Lindstrom, and he told me that my insurance carrier had never been beat. My doctors urged me to sidestep the insurance thing, and I did - we ended up self-paying for my surgery. I went to Spain for my surgery with Dr. Aniceto Baltasar. For surgery, travel, etc., it was $15,000 2.5 years ago. I'm so thankful now that insurance DIDN'T cover and I was able to choose a surgery that works for me, and a surgeon who is one of the best in the world - and is a wonderful person to boot! Let me know if I can answer any questions, okay? Blessings, dina
   — Dina McBride