Question:
How to get around an exclusion clause

Any suggestions as to how I go about convincing the State of Washington Public Employees Benefits Board(PEBB)to allow WLS. I am a state of Washington employee who is obese with multiple co-morbidities and I want to continue working and maintaining my household yet, my insurance as a state employee will not pay for the surgery but will pay for cardiac studies,C-Pap machines,loads of medications for hypertension,degenerative joint disease,depression etc. It is ironic that the state's medicaid insurance will cover this surgery for someone not working but won't for it's state employees or their dependents..any suggestions?    — Deborah S. (posted on September 20, 2002)

September 20, 2002
I have heard on here that some people got their WLS covered by having their doctors writing letters to the ins co requesting els as a treatment for medical illnesses..such as diabetes, heart probs, high blood pressure, stuff like that...my knee surgeon even wrote my ins a letter stating that I already had one knee surgery and need the other done and was looking at total knee replacement within 5 years b/c of my weight and that wls would most probably prevent any further knee surgery. So I wrote the ins a looong letter telling them all of the same things all of my drs had written in my own words along with their prospective annual savings over the next 5 years...I was approved.(My ins doesnt have an exclusionary policy)...open RNY 10/15/02...Good luck and keep after them!!!!
   — cherokey55

September 20, 2002
Not sure if this will work but it is worth a try. You can always do a graph on the cost of treatments for obese care that you had mentioned over the years verus the surgery.
   — Debbie W.

September 22, 2002
Deborah, Ask your HR person if your paperwork can be submitted to the Medical Review Board. I too have an exclusion in my policy, but my HR people said that sometime when people need something that is not covered. They will allow it to go before the Medical Review Board who is made up of a team of doctors. For me they said that if the docotors decide the surgery is medically necessary then my company would approve me to have the surgery. My company is basically self=-insured and used my insurance company as a third party. I haven't submitted my information yet so I'm not even sure that I'll be approved, but at least I have a chance even with the exclusion. Make sure that if you are able to have them review your case that you have very detailed information from your doctors and test results. Wishing you the best of luck!
   — LISA O.