Question:
I am told my insurance policy has a specific WLS exculsion; what are my options?

I am told my insurance policy has a WLS exclusion. I have not seen the actual policy, so I can't quote the exact language. I have had an HR rep at work and an insurance company rep tell me the same thing though, WLS is specifically excluded. What recourse do I have? The way the appeals process was explained to me, it sounds like a brick wall route. I have my attorney looking into this, but it all just came up Friday. I desparately need this surgery done. It is possible I could self pay, but I would be terrified at the potential cost of any complications. I live in Kansas, and I work in Missouri; I have United Healthcare PPO, so if anyone has any suggestions, I'd be more than happy to listen. Thanks, Rowland Fitzgerald    — Biggestfitz (posted on September 27, 2003)

September 27, 2003
You first recourse is to appeal thru your employer...they are the onces who placed the exclusion on your policy. Speak with your HR representative and see if they will help you go thru the proper channels with appeals. One atty who is sort of the guru for helping with cases like this is Walter Lindstrom...enter his name in the library for ways to contact him. Best of luck to you...
   — rebeccamayhew

September 27, 2003
You need to ask your insurance more specific questions. For example, my insurance excludes WLS unless it is considered a medical necessity. Usually that is defined at BMI > 40 and comorbidities such as hypertension and sleep apnea. I found that I had to be very specific when I talked with anyone at the insurance company. At first they rejected everything, but once a pre-determination was approved indicating that I was MO, they paid for everything. All I had to do was to resubmit the previous claims. Otherwise, you may want to check out: http://obesitylaw.com/index.htm.
   — rleffler

September 27, 2003
I was told that my insurance had the WLS exclusion-BCBS and they would NOT budge. I begged, pleaded, sued and cried. NOTHING worked. They would not do anything to change the exclusion. SORRY....Hope its different for you. Good Luck and God Bless you.
   — CARLA C.

September 27, 2003
First you must get a copy of the exclusion in writing. It actually should be listed in the exclusions section of your policy book. Unless it specifically says no treatment or surgery for Morbid Obesity then you have a chance. If it only refers to Obesity then that's your foot in the door and you should not need a lawyer. Make sure any request is then submitted with a diagnosis code of MO and indicated medically necessary and also any co-morbs. If it clearly does exclude it for MO then it's not worth spending any money on in my opinion. But each has to decide for themselves.
   — zoedogcbr

September 29, 2003
I have United Healthcare POS. I did quite a bit of research before my surgery and found out that UHC was one of the better insurance companies to deal with. My UHC policy also had an exclusion, but it was no big deal. The exclusion simply said that they wouldn't cover WLS unless it was medically necessary. I had high blood pressure and elevated cholesterol and a BMI of 50, so that made it medically necessary. There is an attorney in San Diego who has fantastic results getting insurance companies to pay for WLS. http://www.obesitylaw.com
   — aferrendelli