Question:
Wording of exclusion

Hi all, Im hoping someone might know more about insurance than I do and whether I can possibly get approval with this exclusion. Please, anyone who knows anything. Under obesity treatment my policy says. Charges for medically necessary, nonsurgical treatment of obesity are covered when a diagnosis of morbid obesity is given and a comorbidity is present that is aggravated by morbid obesity. Charges from diet centers and diet counseling, including, but not limited to, the cost of food and food suppliments, are not considered eligible expenses. No benefits are payable for any surgical procedure performed for the treatment of obesity or for the purpose of weight reduction. However the plan will cover treatment of complications arising during or subsequent to such a surgical procedure. Then under sxclusions it says Surgical treatment of obesity/weight reduction. If you read all the way through that then thank you so much. What do you think about approval? They dont say no surgical treatment for morbid obesity. But maybe Im just wishing.    — Leslie S. (posted on March 22, 2005)

March 22, 2005
Sounds to me like they want you to pay for surgery, and then if there are any post-op care issues (whether complication, or just maintenance follow-up and counselling) they're willing to cover. Honestly, not bad. Mine has air-tight exclusion for ANYTHING related to weight - whether you're anorexic or morbidly obese. This at least gives you leeway for some good post-op care coverage! Have you considered self-paying? Blessings, dina
   — Dina McBride

March 22, 2005
I think you have a shot, if you are morbidly obese. And where it mentions not paying for procedures for the purpose of weight reduction, you could say that you would like the surgery to correct the comorbidities - or potential comorbid conditions (based on family history - like diabetes, heart disease, arthritis, etc.) - before they affect your health and cost the insurance company thousands of dollars to treat! Go for it!
   — koogy

March 22, 2005
I work for a big insurance company and I know the semantics, email me, personally, I'll help you out. Jen
   — nojust1ce

March 22, 2005
Sun Splash. My insurance read similarly to the way this does, and I had WLS seven months ago. The bariatric surgeons office managed the process successfully and got the approval. Do you have any of the co-morbities like high blood pressure, sleep apnea, diabetes that will work in you favor in obtaining approval. Is your BMI 39 or higher? Have you tried and failed at past diet plans? That willalso help. It sounds good, but let your surgeon's office staff lead the way.
   — Stephanie F.

March 23, 2005
No benefits are payable for any surgical procedure performed for the treatment of obesity or for the purpose of weight reduction. You have to have your doctor word his request for coverage of the surgery some otherthe treatment of obesity t for the procedure diffrent than surgical procedure. It should read something like to reduce or disolve some co-morbids. I pray that you get approved. Good luck
   — JerseyGirl

March 23, 2005
Hi everyone, original poster here, Thank you so much for all your input. I should have included that my BMI is 44 and I have comorbids of asthma, high blood pressure, high cholesterol, pre-diabetes, chronic back pain and swollen ankles, feet and hands. Sorry for leaving that stuff out.
   — Leslie S.