Insurance doesn't cover......

DouglasP13 · October 17, 2006

Okay, I have Anthem BC/BS, and they told me that my policy does not cover any weight loss surgeries. However, they said that I can appeal it. Has anyone here appealed the no coverage thing and won??? Please let me know.

Alexandra · October 17, 2006

Hi Douglas,

The first thing you have to do is find out who would be deciding your appeal. If your company's contract has an exclusion for bariatric surgery, you'd have to appeal to your company. If you have a large-group plan, Anthem BCBS just provides the coverage your employer pays for and won't make exceptions just because you ask or appeal.

If you have a standard plan, find out exactly why it doesn't cover bariatric surgeries and what your grounds for appeal might be. For example, when I first applied to my carrier they excluded lap-banding specifically, but not bariatric surgery in general. On my third appeal I was allowed to go to a third party for a determination (that is, a party other than the carrier itself) and the exclusion was denied. My basis for appeal was that a) I was medically qualified, the policy provides for treatment of my condition, and c) the treatment I wanted was not investigational or experimental (which is their original reason for excluding it).

If your policy has an across-the-board exclusion for bariatric treatment even if you have a diagnosis of morbid obesity, I don't know what your grounds for appealing that might be. So you have to find out exactly what sort of exclusion you're up against. Good luck!!

DouglasP13 · October 18, 2006

Allexandra, thank you for your help. I have insurance through a company, actually it is through my church, and diocese. It would be a large group plan. I called the office to discuss this, and they will find out if they can change the coverage. When I spoke to my insurance company today, they told me that the exclusion is for any weight loss surgery or programs. If my doctors' give them evidence to show that this is for my health and not just to lose weight, do you think that would work?

Thanx again for what you do.

Alexandra · October 18, 2006

Hi Douglas,

It's your company that dictated the terms of the contract, not the insurance carrier. Obviously you should have your ducks in a row with regard to showing it's a health issue, not a cosmetic one, but you'll be appealing to your employer rather than the carrier. I have no idea what your employer may feel about making exceptions or altering the contract; I know it's been done but every employer is different.

You might want to talk with a lawyer, since a case might be made that your company is denying crucial health services to employees in need of medical care. That could be considered discriminatory--would they carve out cancer patients, for example? But really, every situation is different and your best bet is to proceed with your employer.

Good luck!