Employer exclusion question

[Jen40 12]

Is there ever any chance of getting insurance to pay, if it's an "employer exclusion"? I've heard of lots of appeals processes and whatnot... Does this apply? If it's an exclusion to our plan, is there just no hope?

[Bufflehead 6,358]

My understanding is that employer exclusions are usually 100% exclusions, no exceptions for "medical necessity" or whatever. Appeals are usually taken when an insurance plan covers the surgery in general but denies it to a particular person because the company says that person didn't meet their criteria. Then the person appeals saying yes I do meet your criteria, and you are supposed to cover the surgery when these criteria are met, so you have to cover my surgery.

However, I'm not an insurance expert . . . if you have a surgeon selected, there should be an insurance coordinator on his/her staff who can look at your policy and give you specific advice. Good luck!

[McButterpants 2,846]

My insurance doesn't cover ANYTHING weight loss related - it's a complete exclusion of anything weight loss related. I asked the insurance coordinator at the hospital and she said she has never seen a reversal with my exclusion.

With that said, it's worth a try. If they deny, I'd appeal and push the issue.

[Sassy Pants1 186]

Same here. Totally excluded. It's a hard stop for insurance coverage.

[vdub_tx 92]

An exclusion for bariatrics means that they don't cover any type of weight loss surgery at all for any reason. My policy has an exclusion as well. But don't lose hope! Many doctors discount their services for self-pay. I would call the surgeon's office and ask them to go over your options. In my case, it was found that I have a hiatal hernia which significantly reduced my out of pocket costs because hernia repair is a separate medical procedure covered by pretty much everyone's insurance. I know that there are lots of people who have financed their surgeries, either via care credit or a bank loan. Don't give up just yet!

[slvrsax 301]

Interesting question, I wondered about this myself. My insurane also had a specific exclusion for WLS. I didn't bother with appeals, I went to Mexico.

My surgery wasn't textbook. The day after my sleeve, I had a hiatal hernia repaired and scar tissue removed from my esophagas. Apparently I had a great deal of scar tissue from years of acid reflux I didn't know I had. I had no symptoms. In hindsight I wonder this. If my hernia and scar tissue had been diagnosed before hand (with an endoscopy that is part of US pre-op testing), would it have been possible to have the hernia and scar tissue surgery covered by insurance, have it all done at once with the sleeve and paid for the bariactric surgeon fee out of pocket? I bet the price would have been about the same. I am pleased with the experience I had in Mexico, don't get me wrong. It was just something I wondered about. My husband's GI doc told us just last week that a very large percentage of the population have hiatal hernias.

Good luck with finding the resources for your surgery, if there's a will there's a way!

[gohelpyourself 377]

You can only appeal a denied claim. You will not even be able to submit a claim because your policy doesn't cover WLS. That is unfortunate.

[vdub_tx 92]

Honestly I think everyone with an exclusion should have the hiatal hernia thing checked out. They are extremely common, especially in people who are overweight. It reduced my cash price to $8100 which allowed me to have the surgery close to home.

[McButterpants 2,846]

You can only appeal a denied claim. You will not even be able to submit a claim because your policy doesn't cover WLS. That is unfortunate.

Well, this is what happened to me - I knew I had the exclusion before I went to the surgeon for consultation. They submitted the pre-approval paperwork and the insurance company denied it. I could have gone thru the appeals process at that point.

[gohelpyourself 377]

You can only appeal a denied claim. You will not even be able to submit a claim because your policy doesn't cover WLS. That is unfortunate.

Well, this is what happened to me - I knew I had the exclusion before I went to the surgeon for consultation. They submitted the pre-approval paperwork and the insurance company denied it. I could have gone thru the appeals process at that point.

How can you appeal the claim if the surgery is excluded? It is one thing to not know there is an exclusion... your surgeon will not know unless they submit a claim BUT if you know beforehand going in that WLS is an exclusion on your policy your claim will be denied. Appealing it is a waste of time. It is like not carrying collision on your vehicle and getting into an accident and expecting the insurance company to pay for the repairs.

[McButterpants 2,846]

Maybe it's a waste of time, but if it can save you $10,000 or more, I would give it a shot. But that's just me - what's the worst they can do - say NO?

[acnaib 1]

I have insurance that will not pay for WLS. Any one out there known of additional insurance to purchase that will cover the WLS. Or is there any supplement insurance HELP.........

[searching 5]

03/02/2014

Hi,

Interesting ideas regarding insurance. One would think with all the research on excess weigh and inflammation insurance companies would want to pay for WLS but they don't.

It is worst this year in-regards to what insurance companies will pay for.

We have a small business and WLS is excluded. I couldn't even buy a rider.

Searched and looked for insurance we could buy. Only Federal or Medicare were options that were available in our state.

So I will be looking towards the idea regarding reflux and hiatal hernias.

Searching

[Jersrose43 837]

How can you appeal the claim if the surgery is excluded? It is one thing to not know there is an exclusion... your surgeon will not know unless they submit a claim BUT if you know beforehand going in that WLS is an exclusion on your policy your claim will be denied. Appealing it is a waste of time. It is like not carrying collision on your vehicle and getting into an accident and expecting the insurance company to pay for the repairs.

You can't appeal an employer exclusion

It's a benefit exclusion. Just like no benefit for chiropractic care. Necessity isn't a consideration. The benefit is not there.

You can appeal a denial of a precert regardless if a claim has been filed. But this isn't an option here as it's excluded.

Your employer is the one who excluded it. Try to get on another plan such as a spouses coverage