Question:
1st apeal denied Ins Co Verbage Confusing VS Contact with other Members

Letter from insurance states:"Gastric Bypass Surgery is not covered per EDS contract. Under your coverage this svc is not a benefit." BUT I have spoken w/3 other EDS emp. that have had it done...I just don't know what to do... Any suggestions would be soooo appreciated!! — Snowflake48342 (posted on April 2, 2003)

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April 2, 2003
I think what the letter means is that it's not a benefit you're just entitled to. My first denial letter said, "We regret to inform you that payment for the request of gastroplasty is not authorized as the service/procedure requested is not a covered benefit. The reason for denial is that for obesity surgery to be considered, there must be evidence that the member is at high risk and has failed less invasive methods of weight loss...blah, blah, blah. From what I understand, my insurance company isn't going to just approve me without verifying that it's a medically necessary procedure. You should call your ins co to see exactly what you should do next.
— Kimberly S.

April 2, 2003
If possible you need to find out when these people had surgery and what their starting BMI's were and if they had any significant co-morbidities. My guess is that they were considered worse than you with a 41BMI. You also do not list any co-morbs in your profile so that may also be working against you. Just because NIH say 40BMI qualifies you and insurance companies can set their own standards including excluding it. The other possibility is that as of the 1st of the year or something, your employer may have excluded coverage if it. The only way to get to the bottom of this is to dig. It might be that the exclusion can be overridden with significant medical necessity. You have nothing to lose (but lbs) to invest some time in trying to get this resolved. Good Luck, Chris
— zoedogcbr

April 2, 2003
The fact is that exclusions are seldom overturned unless they state EXCLUDED EXCEPT FOR MEDICAL NECESSITY. Then you have a good chance. Good luck.
— Delores S.

April 2, 2003
Print this post to see it better By law when an insurance company denies you coverage for something they say is excluded you have the right to request that they send you the plan policy showing you on what page that is stated. Your Appeal Rights Under Michigan's Public Acts Most questions or concerns about how we processed your claim or request for benefits can be resolved through a phone call to one of our Customer Service Representatives. However, if your health care coverage is underwritten by BCBSM and you believe that we have violated Section 402 or 403 of Public Act 350, Michigan Public Act 350, as amended by Public Act 250, establishes an internal grievance procedure. You will find the specific provisions of those two parts of the act in What We Must Do. What We Must Do Section 403 of Public Act 350 Section 403 provides that we must, on a timely basis, pay to you or a participating provider benefits as are entitled and provided under the applicable certificate. When not paid on a timely basis, benefits payable to you will bear simple interest from a date 60 days after we have received a satisfactory claim form at a rate of 12 percent interest per year. The interest will be paid in addition to the claim at the time of payment of the claim. We must specify in writing the materials which constitute a satisfactory claim form no later than 30 days after receipt of a claim, unless the claim is settled within 30 days. If a claim form is not supplied as to the entire claim, the amount supported by the claim form will be considered to be paid on a timely basis if paid within 60 days after we receive the claim form. What We May Not Do Sections 402 The sections below provide the exact language of the law: Section 402(1) provides that we may not do any of the following: Misrepresent pertinent facts or certificate provisions relating to coverage Fail to acknowledge promptly or to act reasonably and promptly upon communications with respect to a claim arising under a certificate. Fail to adopt and implement reasonable standards for the prompt investigation of a claim arising under a certificate. Refuse to pay claims without conducting a reasonable investigation based upon the available information. Fail to affirm or deny coverage of a claim within a reasonable time after a claim has been received. Fail to attempt in good faith to make a prompt, fair and equitable settlement of a claim for which liability has become reasonably clear Compel members to institute litigation to recover amounts due under a certificate by offering substantially less than the amounts due. Attempt to settle a claim for less than the amount which a reasonable person would believe was due under a certificate, by making reference to written or printed advertising material accompanying or made part of an application for coverage. Make known to the member a policy of appealing from administrative hearing decisions in favor of members for the purpose of compelling a member to accept a settlement or compromise in a claim. Attempt to settle a claim on the basis of an application which was altered without notice to, knowledge or consent of, the subscriber under whose certificate the claim is being made. Delay the investigation or payment of a claim by requiring a member, or the provider of health care services to the member, to submit a preliminary claim and then requiring subsequent submission of a formal claim, seeking solely the duplication of a verification. Fail to promptly provide a reasonable explanation of the basis for a denial of a claim or for the offer of a compromise settlement. Fail to promptly settle a claim where liability has become reasonably clear under one portion of the certificate in order to influence a settlement under another portion of the certificate. Section 402(2) provides that there are certain things that we cannot do in order to induce you to contract with us for the provision of health care benefits, or to induce you to lapse, forfeit or surrender a certificate issued by us or to induce you to secure or terminate coverage with another insurer, health maintenance organization or other person. The things we cannot do under this section are: Issue or deliver to a person money or other valuable consideration. Offer to make or make an agreement relating to a certificate other than as plainly expressed in the certificate. Offer to give or pay, directly or indirectly, a rebate or part of a premium, or an advantage with respect to the furnishing of health care benefits or administrative or other services offered by the corporation except as reflected in the rate and expressly provided in the certificate. Make, issue or circulate, or cause to be made, issued or circulated, any estimate, illustration, circular or statement misrepresenting the terms of a certificate or contract for administrative or other services, the benefits thereunder, or the true nature thereof. Make a misrepresentation or incomplete comparison, whether oral or written, between certificates of the corporation or between certificates or contracts of the corporation and another health care corporation, health maintenance organization or other person. Likewise, if you are a BCBSM member of a group whose coverage is underwritten by a commercial insurer (for example, the Michigan Farm Bureau or the Michigan Dental Association), the state Insurance Code provides an internal grievance procedure under Public Act 252. If we have denied, reduced, or terminated an admission, availability of care, continued stay or other health care service, Public Act 251 of 2000 provides you with the right to request an external review from the Commissioner of Financial and Insurance Services. You must exhaust our standard internal grievance procedure before you can request an external review. Please note: If you have group health care coverage that is both self-funded and is exempt from federal ERISA law, or if you have our Medigap coverage, you are eligible for our internal grievance procedures, but not for the external review procedures of Public Act 251. 
— Teena A.

April 2, 2003

— Teena A.

April 2, 2003
You can also go to the site for statistical data to assist you with your letter http://m-g-b.com/sample_appeal_ltr.htm I also urge you to try to get letters from all of your doctors stating why this surgery is necessary and how they feel it would benefit you. Most importantly though request for them to send you a copy of your contract where it says surgery is excluded. Send everything you send to them by certified or registered mail because insurance companies always say they never received your information. Everytime you call get the name and extention of who you talked to and write it down along with date, time, and what was said . You may need that later on during appeals or review process.Good luck.
— Teena A.

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