Question:
Has anyone found their insurance covered care and excluded care contradictory?

My Background 21 year old male. Morbidly obese since childhood. Started seeking professional help at 14 through which my doctor sent me to be seen each month at Lebohner Children's Hospital. I was experiencing delayed puberty, and my hormone count was all screwed up. Doctors never gave me a diagnosis other than there is something wrong. I went on their supervised diet in which worked for the first month but then soon after did not. After doing this for a while, my parents ended up getting divorced so I stopped going to the doctor. Another year passed. Health wise, getting worse by the month. Go to the doc, more meds and supervised diets witht the help of a nutritionalist. Nothing. I had started to work full time, and this is when my real health problems got going. I have always had shortness of breath, but it has increased severely. I got hemmorhoids, which weight played in that. My legs had cellulitus ( which it turned all red and stuff) and had to take a week and half off of work, and take antibiotics. My PCP thinks I may have sleep anea, because I am tired most all of the time. He referred me to a surgeon and has written a letter of medicall necessity for the surgery. I have a strong family history of obesity, diabetes, and heart problems. Nothing too severe at the moment, but enough where I know something must be done. Ins. I have BCBS of Tn PPO. There is a written exclusion. That is really why I wanted to see what is going on. They told me when they denied me that none of blue cross was approving the surgery anymore. That is such bull crap. the exclusion states: Excludes: Services of supplies related to obesity, including surgical or other treatment of morbid obesity. Ok. Sounds pretty iron clad. But my book also says.....Covered: MEDICALLY NECESSARY AND APPROPRIATE SERVICES AND SUPPLIES IN A HOSPITAL WHICH IS 1)A LICENSED ACUTE CARE INSTITUTE. 2)INPATIENT SERVICES. 3)HAS SURGICAL AND MEDICAL FACILITIES PRIMARILY FOR THE DIAGNOSIS AND TREATMENT OF A DISEASE AND INJURY. 4)HAS A STAFF OF PHYSICIANS LICENSED TO PRACTICE MEDICINE AND PROVIDES 24 HOUR NURSING CARE BY GRADUATE REG. NURSES. This is what I am talking about. I know that we all have heard the obesity is now regarded as a chronic medical disease by the National Ins.of Health. I even fall into that category of super morbidly obese with a bmi of 54. I am sorry to go on this spill. any suggestions. tell me about yourself and the process. I would like to hear any suggestions or comments.    — Matthew P. (posted on April 8, 2004)

April 8, 2004
Hello, I am experiencing about the same thing you are. The online benefits says "excludes treatments for weight loss" then the rep on the phone tells me it is a convered benefit in my policy, and read it to me word for word. I am getting ready to submit for approval. I would suggest calling them and talking to a rep. maybe you can fax the paper you have saying it is covered. Also, I would ask if there was any policy change, and make them provide it to you in writting. Best of luck to you.
   — MS. A.

April 8, 2004
Matthew,<br>The second quote from your policy is for all procedures. That quote is defining what facilites are covered and for what services are covered. The first quote is from your limitations and exclusions page. Meaning, we cover hospital stays for medically necessary items. However, we specifically will not pay for WLS.<br> <br> Neither of those quotes contradict themselves as they are both talking about different things. <br>Unfortunatly you have an iron clad exclusion. You would be wasting your time and money trying to fight such a thing. My suggestion would be to try and obtain different coverage or find some way to self pay. I don't mean to come off harsh or uncaring here, I do understand your frustration and where you could be confused with these to quotes. But they truly are unrelated. Rebecca
   — RebeccaP

April 9, 2004
Matthew, the best thing you can do for now is call your insurance company and speak to a customer service rep. Make sure to document (take notes) of everything, including the rep's name and the date and time you spoke. If the rep doesn't seem to give you a satisfactory answer, ask to speak to the supervisor. It is possible that the statement in the book is an overall policy that is modified by your particular plan's exclusion policy. Recently BC/BS of Florida announced that, as of 2005, they would no longer be covering WLS. Many other insurance companies (including mine) will be following suit, unfortunately. I wonder if, if your health problems were severe enough, that could be listed as the reason for the surgery - rather than being for weight loss. It is hard for insurance companies to deny for something really medically necessary. BTW ... if you get denied, make sure to write to the insurance company and appeal their decision. Have your doctor provide them with as much documentation of your co-morbities as possible. If they deny that, and you don't think asking for a second level appeal would help, contact your state health department (the denial letter should give you the state's phone number) and ask them to appeal on your behalf. You'd be surprised how well that works - IF your doctor provides enough documentation of medical necessity! Good luck!
   — IleneRachel

April 12, 2004
I am writing with things along the same line as Ilene below. I would double check with your insurance company also to see of it is covered "if it is medically necessary". You seem to have a multitude of evidence on your side that you really need this surgery, (seeing Drs for obesity since you were 14 yrs old). IF YOU FIND OUT THAT YOU CAN BE COVERED BECAUSE OF MED NECESSITY, there is an abundance of material on this site to help you. Sharon Brittain has an awesome letter on her site that shows co-morbs (I thought I had 10-12 prior to getting my letter together, but after using her list had over 50) and she also shows you how to make a family history chart. Any/all info you can send to support your case will help in getting approved. ANY/every Dr that you have seen for problems with your weight/health issues, I would get a letter from them to send in stating that you need this surgery. Also Rona Scott has written a SUPER piece on here (in the library) on the costs of morbid obesity and how having this surgery can reduce costs and illiminate some health problems. (When I typed this out in a formal letter, it was over 6 pages long). In your personal letter to insurance company stress that you need this surgery and that this is for a medical necessity. I hope to God that ALL BCBS are not going to exclude this surgery. I feel this is the last discrimiation in America. I will be praying that you can get approved, if not thru this company, then thru another one. DO NOT EVER GIVE UP!!! Your life is depending on it. I had to wait almost 3 yrs to get approved, so I know how frustrating it can be. Please keep your file updated on here, in case anybody sees your question later and can send e-mail and give advice in the future. Oh, one more thing, if you can write your congressmen and representatives and see if you can try to get WLS made mandatory for your state. I think there are 4 states now that must give WLS to people in need. Good Luck!! Prayer works!! It helped me many many times when I thought I couldn't go any further in my WLS quest.
   — bufordslipstick

April 12, 2004
P.S. check out the "Is there a way to get" question on WLS exclusion question on Q/A board above for possible help
   — bufordslipstick