Question:
Has anyone gotten approved after being denied due to unclear exclusion?

I have Humana Choice care PPO insurance and I have called twice and asked about exclusions in my policy, both times I was told there was no exclusion. Today I got word that I was denied due to an exclusion in my policy that states: any treatment to reduce obesity including, but not limited to, surgical procedures. Now I don't know if I have a chance or not. I have read one other posting about this where the person was in Texas and it was overturned at the panel review. Does anyone in Kentucky have any experience with this?    — Pamela F. (posted on June 7, 2004)

June 7, 2004
Its always wise to get names and dates of who you spoke to and always ask them to fax you what they told you verbally in writing. You should have a booklet explaining all of your benefits vs having to call. I would ask for them to send that to you. An exclusion is hard to fight but has been done. Good Luck!
   — ZZ S.

June 7, 2004
Pamela, Have you contacted any of the attorneys who specialize in dealing with WLS related insurance issues? Try contacting either www.obesitylawyer.com or www.obesitylaw.com - also, Diana Cox is a member here at AMOS and has a great story about how she fought her way toward insurance approval. Keep in mind as well, the option of self-paying. I know a couple of people in Kentucky who have my surgeon (Dr. Aniceto Baltasar in Alcoy, Spain) that I could put you in touch with. Blessings, dina
   — Dina McBride

June 8, 2004
From my understanding there is a loop hole in what you have said your denial states. For you tko qualify for WLS you have to have a BMI of over 40 right???? Well that gives you a diagnosis of "MORBID OBESITY" not "Obesity" that you say your plan does not cover. There is a difference in the two diagnosis and there are two different diagnosis codes for them. Therefore you have a valid claim since they state that they don't cover obesity they do not say anything about "Morbid Obesity". Contact a lawyer and see what they say about it. If you pay the premium then you have the right to have it covered. Some states (GA, AL) have passed laws that say it is not legal for an insurance company to have exclusions for something that is medically necessary. Good Luck....
   — mowermen

June 9, 2004
I was denied by my insurance (Kaiser HMO). I went through their grievance procedures and was still denied. I didn't give up and went to the Department of Managed Health Care (CA) and won. According to the NIH if your BMI is over 40 you should qualify for this surgery. Please read my profile for the whole story.
   — Amy L.