Question:
I have been denied twice what next?

My insurance co. has denied 2X . they say even if surery is medically necc. They will not pay due to exclusion " no weightloss/obesity surgery" The 1st time I was denied I went to HR. They inturn sent it back to in. Co. for "review" and it was denied again. someone please tell me where to go next. My. Dr suggested Walter, Which brings me to another question, If anyone has used Walter and you don't live in Cal, How much is He? (approx.) Thanks    — Cindee A. (posted on April 18, 2001)

April 18, 2001
I live in Oregon.. and have talked w/ Walter but haven't retained him yet.. I will be in the same boat though with my insurance its clearly an exlcusion. Is this an employer policy you are on? Is this considered self insured? Talk w/ HR about the exclusion find out if they will review this and reconsider this. Talk w/ your insurance company and find out how many appeals you have. Talk w/ someone in your city with the insurance commission get them involved. Involve your Senators, Congressman, Mayor and Governor. Do some major research on your insurance company and find out if they are likely to ever pay for this. If all else fails.. seek out private insurance, look for a new job etc.. these are all options I'm considering.. they all aren't exactly what I'd like.. my first goal would be to stay where I am with the benefit I need and deserve. I have worked in the insurance industry here in Oregon for well over 8 years and am here to help if I can. I wish you the best of luck.
   — Dawn R.

April 18, 2001
If it is 'clearly' an exclusion, then it is not and will not be covered. Quit banging your head against the wall. Move forward with other options. One is self pay, there are a number on this site who went the self pay route. Sell your car, your boat, your whatever, get a second mortage or home improvement loan on your house, borrow from relatives, do a fundraiser, get a second job, get your spouse a second job -- whatever it takes, the surgery is worth it. Often, you will find a doc and hospital to work with you on self pay as an option. I'd stop wasting time appealing a clear exclusion. No employer HAS to cover every possible surgical procedure out there. Some are excluded from every policy. Sorry, just move forward. Brainstorm. Best wishes.
   — Cindy H.

April 18, 2001
HI CINDEE MY NAME IS KAREN AND I AM FROM MEMPHIS TENNESSEE. I WENT THROUGH SO MANY PROBLEMS WITH MY LAST INSURANCE COMPANY CIGNA HMO. A PERSON ON THIS SITE SUGGESTED I HIRE WALTER LINDSTROM. WELL I DID AND IT COST ME 750 DOLLARS JUST FOR A LETTER AND A OVER THE PHONE CONFERENCE. I WAS VERY UPSET BECAUSE A LAWYER HERE IN MEMPHIS TOLD ME THAT WAS A BIG MISTAKE. HE TOLD ME THE OBESITY LAWYERS ALREADY KNOW WHO WILL APPROVE YOU OR NOT. SO IF YOU HAVE AN EXCLUSION PLEASE DON'T WASTE YOUR MONEY. I WENT THROUGH 3 REGULAR APPEALS AND MY LAST FINALE APPEAL BEFORE THEY BROKE MY HEART AND TURN ME DOWN. IT TOOK ALMOST 8 MONTHS. CONSIDER CHANGING YOUR INSURANCE IF YOU COULD. I FELT SO BAD BECAUSE MY JOB CAN ONLY CHANGE INSURANCE ONCE A YEAR. IT WAS JUNE WHEN THEY TURNED ME DOWN AND I CHANGED MY INSURANCE IN OCTOBER. MY NEW INSURANCE UNITED HEALTH CARE WENT IN EFFECT ON JAN 1ST 2001. I WAS APPROVED IN 8 DAYS AND HAD MY SURGERY ON MARCH 19 2001.
   — fradycat007

April 18, 2001
Cindee..sorry..but at some point you give up...I fought for entire year..all that you can do..even spoke with Lindstrom..I have double ins coverage and even though it iritated the heck out of me I had to move on and decide my surgery was just too important to me...I spent the year not only fighting(because I felt I had to) but saving up the money...I ended up being a selfpay but I could go anywhere in the country to have my surgery..therefore, I went to the surgeon I thought was the best for a LAP RNY and I only spent $18,400.00 for the best...best money I have ever spent!!!!(LAP RNY 1/16/01 56lbs down)
   — Debora H.

April 19, 2001
I have Health Alliance Plan. There is an exclusion against WLS that was pretty much airtight. After my first letter of declination I hired Walter Lindstrom and it was money well spent. First of all the letter that he sends is almost 40 pages. He follows your appeals process to the end which includes more letters if applicable and phone calles to your insurer. He also represented me at my final appeal level which was a conference with myself, panel board from the insurance co. and Mr. Lindstrom. I was still denied because HAP thinks that WLS is cosmetic and not a medical necessity. Well the final option was taking it to the Center for Health Dispute Resolution's (CHDR)which is the state level. It was found that it was medically necessary that I have WLS and HAP's declination was overturned and I will be having my surgery on 04-26-01. That was $750.00 well spent because I have no out of pocket expenses.
   — Margaret M.