Question:
Has anyone actually had a Exclusion denial reversed?

I have been given a surgery date and then have been denied because of an exclusion in the companies contract with Waste Managment who is my wife's employer. They seem to have had no problem paying for all of the pre op office vists, tests etc. I am in the first round of appeals and hope to reverse the decision. Any information is appreciated. I live in PA and the insurance is Healthone.    — kyle B. (posted on October 23, 2001)

October 23, 2001
As for as I know you can not have it over turned. An Exclusion is every Employers right when they choice an insurance package for their employees and it all has to do with cost. The less amount of coverage for the dollar is what Employers try to look for. And since they pay when choicing their policies the bulk of the cost for your medical expenses, they decided what provision will and wont be included in their insurance packages so save them money. It's not the insurance company it the Employer who is chosing this package with its exclusions.
   — Gwen M.

October 23, 2001
Kyle, I work for a company who carries United Healthcare insurance and I was denied based on that same type of exclusion. If you have not done so already you need to make sure that there is not an UNLESS MEDICALLY NECESSARY clause in there. If it states it is an exclusion unless medically necessary then they have to cover it if your Dr provided the adequate information. If its in there and your Dr. provided the info and they still don't want to cover it get yourself a lawyer, I was told this is becoming more and more of a problem with companies and insurance companies. Luckily that clause was in mine and I did threaten lawsuit, I am now 10 days postop and found out the day before my surgery that it was covered. I wish you the best and sock it to em.
   — Jennifer G.

October 23, 2001
Kyle, Fight it! I am also fighting an exclusion that says they wont cover treatment for"obesity due soley to overeating" We are talking to the company plan administrator and she is trying to get it approved by naming it "genetic instead of soley to overeating".Afterall Morbid obesity is a disease that has many contributing factors. The insurance company can only deny based on the companies chosen plan and exclusions.
   — Patricia R.