Question:
Someone please look at this exclusion and let me know if it applies to WLS.
My company is changing to UHC on 9/1/02... I have yet to receive an office COC to see if it mentions anything speically about WLS, but I was sent a general Exclusions and Limitations page and it has a section that address Physical Appearance and reads ".... Weigth loss programs for medical and non-medical reasons.... " Is this is the same exlusions that is keeping everyone else from having WLS, or has someone with the same vague exlusion gotten apporved. Thanks Rob — Rob C. (posted on August 20, 2002)
August 20, 2002
It sounds like your company can use that to deny you; however, you should
try just the same. You really never know. My insurance company just started
covering WLS. If you ask me, it's worth a try.
— Sarah K.
August 20, 2002
Rob - Like the previous poster said, they may try and initially deny you
but WLS is a surgical procedure not a "program" and WLS addresses
more issues/problems than just physical appearance. The way my PCP
explained it was, if it's medically necessary then it's his/her job to
fight the insurance company for you instead of you fighting them yourself.
Hope all works out well for you - DLC (awaiting insurance approval)
— Dena C.
August 20, 2002
It seems rather vague. Are they referring to weight loss programs as in
Weight Watchers, Nutri-System, etc., OR are they referring to Weight Loss
Surgery - do you see what I mean? I would wait until you receive your
actuall policy/Summary Plan Description OR call now and get clarification!
— Rosario T.
August 20, 2002
I have United Health Care and I was approved for surgery
within 2 weeks after submitting all the information they
they required. Good luck. My company switched from Cigna to United in Jan.
2002, and I been really pleased with the results I have had with them.
— Cathy S.
August 20, 2002
Rob,
I really don't know if my insurance has this same exclusion, however I can
tell you I also have United Health Care and was approved on the first
request.
Hope this helps,
Deb Van Ness
— Deborah K V.
August 20, 2002
When UHC adds a WLS exclusion it is VERY clear. This is not the WLS
exclusion. It will read something like.... Surgical procedures used for
obesity are not covered, however morbid obesity is. That is how mine read.
The ones that exclude it entirely do not have the last statement and add
morbid obesity along with just obesity. UHC contracts are pretty standard
and clear on this subject.
— RebeccaP
August 20, 2002
Rob,
They would not cover Optifast or Medifast fees. They would not cover
Adipex and the list of diet pills that I had taken. They are secondary for
me now and they did pay the deductible for medicare when I had the surgery.
— Mary H.
August 20, 2002
Rob, I have uhc-ppo and my exclusion and limitations section reads that if
you have a dx of morbid obesity and it is medically necessary then it is
covered. Uhc is pretty good about covering this surgery.
— tonia W.
August 21, 2002
My insurance had that same exclusion and it does NOT pay for anything
regarding weight loss. I am currently looking for any loopholes I can find.
— Stephania H.
August 22, 2002
Rob,
I work for an insurance broker and I also have UHC. The vagueness in the
exclusion is usually not bad news. When they say weight loss programs it
means weight watcher, jenny craig, etc. All you have to do is call the 800
number and flat out ask them if "morbid obesity" surgery and
treatment is covered.
It took me a long time to get my Summary Plan Description too. This is
going to be your Bible. When I got mine it had in covered benefits,
"treatment for morbid obesity including surgery." I have the
EPO, but I know people who have been on the HMO and PPO who have also had
the surgery covered. Depending on your policy wording you might have to
fight with them a little. if you have co-morbities like diabetes, high
blood pressure and high cholesterol it will help get them to say yes.
Hope this helps!
Rue
— Ruesnod
August 22, 2002
I have BCBS of GA, I have an exclusion policy that is much more specific,
in fact it states any treatment and or surgery related to obesity is
excluded. Yet, when I called my insurance company they said I could get
the surgery if I proved it medically necessary. I'm just waiting for my
appointment with my surgeon to start the process. You might have to jump
through a few more hoops but from some of the people I've talked to it's
possible to still get approved even with an exclusion. Good luck:)!
— Kimmie C.
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