Question:
Help! I need to know how to appeal my company on an excultion for WLS.
I have been denied for WLS becasue of an exculsion in the policy. I have been told by my doctors if I don't get the surgery I will die. I have letters from my surgeon stating my health problems. I continue to get denied. Any suggestion on an appeal letter to Human Resources? THanks, [email protected] — BonniePTA (posted on September 6, 2003)
September 6, 2003
Unfortunately, HR most likely isn't going to be able to assist you. If the
insurance policy doesn't include the gastric bypass coverage, then it is
their choice to deny your surgery. HR can't change that just for you, they
could only add the gastric bypass rider to the group policy, thus covering
all employees--something I'm sure they won't do. They may, however, add it
upon their next renewal period. I would think your appeal letter should go
to the insurance company. How it reads would all depend on the basis of
their denial. Good luck!
— CindyOakes
September 6, 2003
Unfortunalty, no matter what anyon else tells you, you're "Shit outta
luck." Your're not gonna win, get used to it, and then find
alternatives. If you can afford approx. $30K you can get it done in the US,
if you can't you can get it done for under $5K in Mexico...go to the Yahoo
groups, RNY Mexico. Lots of people have had it done there, and I, for one,
would feel very happy there. Good luck to ya!
— sandieguy
September 6, 2003
Have you tried obesitylaw.com.
— faybay
September 6, 2003
How does the exclusion read? Please detail it out so we have a better
chance of seeing if there is an opening for approval.
<p>There are some surgeons in the US that will do an RNY for around
$13,000. Do a search in the library under self-pay and see what you come
up with. I know a couple of doctor's have been mentioned in the past 8
months. One was in Washington State.
— zoedogcbr
September 6, 2003
There is a surgeon in Brazil who does DS for ~$8000, and another in Spain
who charges ~$12K. They're both highly regarded and the price includes the
hospital. Both have Yahoo groups, too. I hope you'll research the DS at
duodenalswitch.com. Post op eating is easier, there are fewer
complications, and the rate of regain is very low.
— Chris T.
September 7, 2003
Okay...here's the deal. I work for an insurance company and I'm working on
a degree in HR. You're HR dept originally designed the policy. They may
have had some input from the insurance company, but, ultimately, it was
their decision not to cover the surgery. Therefore, they are the ones who
are going to make any changes. You should either have a Benefits Rep in
your local HR dept or some larger corporations have 800# you can call. At
that point, you would need to ask what you need to do to do a benefits
appeal. They SHOULD have specific guidelines to follow. Some companies
have forms to fill out. Some companies may just require a letter and
supporting documentation. You probably aren't out of luck. However, you
do need to follow their directions to the letter.
— Tiffany D.
September 7, 2003
Chris Tabor - Why do you feel the need to push the DS so heavily. Your
post is the same in many questions and most or all of them never asked
about different kinds of surgeries. I'm glad you are happy with your
chosen surgery. Well I am happy with mine also, but I never push an RNY on
anybody. If they are asking about DS I will always point them to
duodenalswitch.com or the DS forum on here or Yahoo DS group. Feel free to
contact people directly via their e-mail. It gets a little old reading the
same post over and over when it doesn't even apply to the question.
<p>I'll put my 162 lb loss in 7 months up against the DS any day. I
know I can be successful because I chose the surgery I can deal with best,
just as you did. Neither of these surgeries is the right answer for
everyone and that is why some chose the AGB or VGB also. It is more
important that a person chose the surgery they can comply with, and yes I
was a SMO and have do doubt I can achieve the same success long term as any
DS person because I had the RIGHT surgery for me!
— zoedogcbr
September 7, 2003
Chris D., I've seen you post about DS and I thank you for that. The reason
I mention it is because so few people know about it. It has no celebrities
to publicize it, unfortunately. There is also not much info on AMOS, and
some of it is misleading. And some people have heard strange untruths or
half-truths about it. I was glad someone clued me in on it when I was
pre-op, so I try to pass it along. Just like everyone else, I'll continue
to post whenever I feel like it, and those who are bored or annoyed can
skip right past. Congratulations on your fabulous weight loss, Chris!!
— Chris T.
September 7, 2003
You MAY have a chance with an appeal to your company's HR dept. IF your
insurance plan is self-funded, and the insurance company is only
administering the plan. This is because a self-funded plan can pay for
whatever they chose to pay for. Otherwise, plan on appealing through the
entire internal review process and then to external review and see if you
can get satisfaction there. If that doesn't work, unfortunately, you will
indeed have to be self-pay, or get a different job with different
insurance.<P>
And I second Chris Tabor's suggestion to look into the DS before you make
any final decisions. Diana
— [Deactivated Member]
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