Question:
Here is the exact wording of my policy on WLS...
"Health Services and associated expenses for the surgical treatment and non-surgical, medical treatment of obesity (including morbid-obesity) are excluded." It just confuses me that they added "are excluded" to the end of that restriction, but not others such as... "Health Services which are not medically neccessary." or "Personal comfort and convenience items or services such as television, telephone, barber or beauty service, guest service and similar incidental services and supplies." or "Penial implants for the treatment of impotence having a psychological origin." See what I'm getting at? They have a list under exclusions that starts with A and goes through AI...they only make statements about what is NOT covered, but have "are excluded" at the end of the WLS statement. Are they saying that medical treatment for obesity and morbid obesity are excluded from the exclusion? Or did they just mess up and add "are excluded" to that one restriction by mistake? Seems like they would make each statement in the same manner... I'm confused... — Shelly T. (posted on August 28, 2000)
August 28, 2000
Unfortunately, I believe that the statement is very clear, it is saying
that all of the treatment relating to obesity, including morbid-obesity are
excluded. I think they said that because some insurance's differentiate
between obesity and morbid-obesity. But I say do not let this stop you,
apply anyway and appeal if necessary, but don't give up.
— Jamelle S.
August 28, 2000
Unfortunately it sounds fairly iron clad if you try to have this surgery
because of morbid obesity. Another way acording to information I received
via another member via Walter Lindstrom is this: Quoting part of original
email "For instance, diabetics or persons with severe reflux or sleep
apnea are often able to get surgery after an initial denial because the
surgery is not for ""weight loss"" but rather, as
primary treatment for comorbidities." I hope you understand what I am
getting at. Just another way to get on the horse. The objective is to get
the surgery. Seems like these companies, with their archaic minds keep
thinking weight loss is a cosmetic thing only...we know better but they
have the $$$ power. Focus on your co-morbids. Good luck.
— JennyLynn A.
August 28, 2000
Another thing that came to my mind after I posted was that in previous
posts I have read there is a case of medical necessity. For them to deny
you treatment for something medically necessary can be illegal. The thing
is all the haggling takes time and you need to try this the most
straightforward way that should bring success. Walter Lindstrom also
mentioned there is caselaw that supports what I detailed in my previous
post. I am not a paralegal, but if someone is please cite these caselaw
#'s on this site to help all who may need them in their appeal letters.
Now I am probably stepping on the toes of the legal profession.
— JennyLynn A.
August 29, 2000
Being an insurance counselor, I can tell you they mean that treatment for
obesity is EXCLUDED period. However, as someone else mentioned, do not
give up. Concentrate on the other comorbities that are consequences of
your morbid obesity. Sleep apnea, diabetes, high blood pressure are all
reasons to have the surgery and could be used as leverage. Good luck to
you.
— Sonya H.
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