Question:
My husband's health insurance has the following exclusion:

"No payment will be made under this Plan for expenses incurred by an employee or a dependent:For charges for the treatment of obesity, weight reduction or dietetic control". BUT, a covered expense:"A Covered Expense shall mean a service or supply which is provided to a Covered Person, and which service or supply is: 2)Recommended by a physician; and 3)Medically necessary for the care and treatment of a covered illness or injury of a covered person; and 4) Provided by a Health Care Provider of these services or supplies". Based on this, do I have any chance of being approved for WLS?    — Mari T. (posted on April 6, 2002)

April 5, 2002
Hi! Mari. I live in GA, and have BCBS Blue Choice HMO. The exclusion in my policy reads almost the same. Notice it says obesity, that diagnosis code is 278.00, it doesn't say morbid obesity, diagnosis code 278.01. To me that is a good indication, along with what is written under Covered Expenses. I called my insurance company and told them I had talked to my PCP about having gastric bypass surgery and I wanted to know if my policy would cover it. I was told that if it was medically necessary, it would be covered. I feel that if your PCP feels this surgery will benefit and feels that it is medically necessary, he/she would gladly write you a strong letter of medical necessity. It would also work to your advantage to stay inside your Provider network, seeking a surgeon within it (let me stress here if upon investigation of surgeons in your area you find no one you feel as adequate, call insurance company about your fears, see if they will approve a surgeon out of their network). It seems to me you stand a good chance, but you won't know for sure until you make that first call. Remember, also, to keep good records of who you spoke to, what date you spoke to them as well as the time of day. I'm in the middle of my insurance voodoo dance, but it looks very promising. I know the dread, and anxiousness about calling the insurance company. But we have so much dread and anxiousness to deal with because of our obesity, yet there are times we must deal with it and this is one of the times, but this time it's for you and you alone. A chance to do something wonderful and beautiful for yourself, how long has it been since you've made yourself your number one priority. I'm sure your a loving, caring, compassionate person to those you care for, please be strong and do the same for yourself, be ruthless if necessary, but don't ever give up fighting for your good health and emotional well being. Jo-Dee Hortz
   — tinyjo

April 5, 2002
I feel sure your insurance will pay if medically nec. My had almost this same statement and I got approved after some stuff from physician and some tests proving that it was med. nec. I would proceed if I were you it was worth it in my case and if they deny it you can appeal with pointing out the med nec. Diane H.
   — diane H.

April 6, 2002
Speak to your health insurance company. I just went through the same thing. MORBID OBESITY is different from OBESITY. Although to the average person we don't think of a difference in medical and insurance terms they are. My insurance does not cover for obesity but did cover for Morbid Obesity
   — Diane Rhoads

April 7, 2002
I am a claims examiner and one of my jobs is to interpret plan language. In your case it reads like the diagnosis of obesity whether it be medically indicated (morbid) or not is specifically excluded under the plan. BUT every company is different, it doesn't hurt to fight.
   — Ronda E.

April 8, 2002
I would think that that was covered, it sounds like it,,,althought, my insurece stated that morbid obesity was covered,,,and then i was denied twice,becasue, i did not have enough problems being morbidly obese,and becasue the surgery was not the norm for handling obesity,really,,so, had the band done in mexico out of my own pocket,,good luck to you (band done jsut over 2 weeks ago, down 11 pounds)
   — amy T.

April 8, 2002
At least give it a try. What do you have to loose? except a lot of weight. Acording to Walter Lindstrom at obesitylaw.com, if a policy does not specifically exclude surgery for morbid obesity, especially when there are serious weight related health problems, then legally it may have to cover it because morbid obesity is a different diagnosis that just obesity and that you are also treating the weight caused health problems, not just trying to loose weight. I would recommend, especially if you have any weight related health problems to contact them at obesitylaw.com. They helped me get approved and the cost was less than $400.
   — Dell H.