Question:
I HAD CONSULT WITH SURGEON

insurance sent me a statement tell me that treatment or surgery for obesity,weight reduction,or weight control are not covered under my plan... But the paper i got when i signed up for the insurance does not state anywhere on it that it is excluded.... WHAT CAN I DO?????? DO I HAVE ANY CHANCE AT GETTING IT APPROVED????? HELP!!!!!!!!!!!!!!!!!!!!!!!    — SHERRY M. (posted on November 30, 2002)

November 30, 2002
Pick up your benefits booklet and look under the exclusions section and find where it excludes what they have indicated. First, if it isn't in there, then question why it isn't spelled out in your policy. 2nd, if it is in there what you may find is that it is excluded but not in the case of morbid obesity. That is the way my BC/BS policy reads. In 1996 I applied to BC/BS for them to cover Redux. They came back and denied it. I called them up and asked if they do not bother to read their own benefits book and pointed it out to them where it was indeed covered in my book. While it did not address Redux specifically it addressed treatment for MO. Then they said that my doctor had to submit a comprehensive treatment plan, not just the letter he did. So I put everything down on paper for my doctor and told him what things had to be covered in the letter - current weight, previous weight loss attemtps, exercise plan, dietician follow-up etc. Then it was approved for 6 months. We even submitted for a 6 month extension, because I had lost 35 lbs on it, which they approved. So dig and dig and dig till you are blue in the face. Pesonally, if this is the treatment for you, then I would go all the way through the appeals process. Insist that you be allowed to present your case to the appeals board. You will need your doctor to do his job in presenting your case, but first help by putting together as much info as you can so he doesn't miss anything that could help. Just help remind him or her. I have two 4" thick medical files for just the past 7 years and I know better than my doctor the total picture and about when things occurred etc. I have asked him to write me a letter to the surgeon providing info that he can use to get my approval and I mentioned everything I could in my letter to help my doctor do the best possible job. He's a great internist but way overloaded and the more I help the better job he ends up doing for me. Some people would be apalled at having to get that involved but it works for me. Some policy's, including my current one (I change to BC/BS on January 1st, 2003), come right out and say they will cover nothing including in the case of morbid obesity. I'll keep my fingers crossed you are successful in your insurance fight!
   — zoedogcbr