Question:
TML Exclusion

I have read the messages related to specifically written exclusions in insurance policies, and am becoming disheartened... My wife is in need of Open RNY, and has everything in order with the surgeon....except the insurance approval! Our TML policy clearly states "The Plan does not pay for medically necessary or non-medically necessary surgical procedures for obesity." The person we called at TML said there wasn't any point to our pre-determination request, for it will be denied. Is that the way it goes? Has anyone been successful in getting an approval within TML Insurance with such a restrictive insurance policy stated? She MUST have the surgery--it is a matter of life and death--and we will pay all of the costs ourselves if necessary, but sure would be nice if at least half of the $25K cost could get covered through the insurance. We do not want to do anything that involves a lawyer, so is it better to just give up right now and self-pay the surgery?    — Ken C. (posted on April 26, 2003)

April 26, 2003
If it says "...surgical procedures for obesity" and not "...surgical procedures for obesity or morbid obesity" then you may have a chance. Why don't you want to at least talk to Walter Lindstrom at http://www.obesitylaw.com and see if he thinks your wife's case is winnable? If you are willing to pay $12,500 as you say in your post, wouldn't it be worth the cost of Mr. Lindstrom's services to pay a lot less than that? <p> You may want to also investigate getting the surgery done else where if you are going the self-pay route. A fellow obesityhelp.com member - Latrisha Nickle - had her RNY done by Dr. Aguirre in Ensenada, Mexico and is very happy. I think her surgery only cost $6500. Look at her profile for more information. I am sure that you could e-mail her via her profile for more info if you were interested in pursuing this option....JR
   — John Rushton

April 26, 2003
Have every doctor your wife has seen regarding her weight issue write a very detailed letter of her case. Include in that letter a list of the medications and treatments she will be on the rest of her life if she doesn't get this treatment and those medications and treatments annual cost per year. Make sure to note that in the next 10 years it will cost them said amount for treatment for your wife's problems vs a one time fee of the surgery. Given the rate that medications increase, the cost of doctor's visits and hospitals stays will out weight the cost of surgery. Let's face facts that insurance companies don't want to pay for surgery because it is expensive. They want to save money, but by showing them that they aren't going to be saving money you may be able to persuade them to pay at least half of the surgery costs. And because this surgery is life or death, as it is with a lot of us, in fact, all of us...as obesity robs us all of years and years of life...explain to them in this letter that your wife will die without this surgery. Make sure your doctor lists EVERYTHING wrong with her and how long she has had the issue and the projected cost of treating these and any other issues that may develope because of these issues. God Bless.
   — Renee B.

April 26, 2003
I was denied,my hosp. knocked off 33% for full payment Antes.15% Be sure and ask for discounts.
   — Rusty A.

May 1, 2003
Thanks for the responses...especially the comment about using the words Morbid Obesity...my wife called the insurance company yesterday, to check on how things are going with the pre-determination request, and received a tiny glimmer of hope when she noted to the representative that the exclusion does not state "morbid" obesity, and he said "that is true." Has anyone gotten approved in such a case, where an insurance policy states "obesity" as an exclusion, but not "morbid" obesity?
   — Ken C.