Appeals??

luv2bingo07 · December 2, 2004

Greetings all,

If you read my last post title "Flipped out Angry :(",

then maybe you can help me with the problems I may be facing trying to get approved for the Band surgery.

I have read about people filing appeals and most eventually getting approved for the surgery, but I just don't know where to go from here. It's like what I found out about my insurance is written in steel and I really feel blocked and lost.

Please help me get started on what I should do next. :cry

Thanks so much!

Judy

Alexandra · December 2, 2004

Hi Judy,

I saw the text you posted in the other thread, and sure, that looks like an iron-clad exclusion. However, those benefit booklets are standard language, and are OFTEN overruled by riders to the contract or state laws. I'm an insurance broker and I see contracts all the time that include provisions that are illegal in New Jersey. The benefits booklet is just the start. For example, the part you quoted only talks about "obesity" as a condition. But "morbid obesity" is a DIFFERENT condition, and that exclusionary language might not apply if you have that diagnosis.

Have you seen a doctor? Have you established the diagnosis of morbid obesity? The first step is always, no matter what, a physical examination by a primary care physician to establish the diagnosis. Then you see a surgeon (whether you need a referral or not will depend on your plan), and at that time you can further discuss your options. You'll have to establish a history of medical care for your diagnosed condition of morbid obesity and your visit to the PCP is step one.

The bottom line is that if we expect the insurance carrier to treat MO as a condition that needs surgical intervention, we have to establish that we are making attempts to treat it in other ways. Surgery is always a last resort, understandably, and getting that medical diagnosis and a record of treatment is crucial.

So that's where you start.

lauri · December 5, 2004

Hi Judy, I am in the same boat! I feel so overwhelmed by the thought of an appeal. The insurance company seems like a BIG dog and me...... the bone! I have been chewed up, spit out and now I am afraid to approach it again. For right now, I am just trying to take care of me and-like you figure out the appeal thing. The last time I talked to my insurance they told me, "go ahead and file your appeal so that it can be rejected again and then you can make your appeal through TRS(Teachers Retirement Services)"

I was so confused I just said, "OK". I will probably talk to my PCP next week or maybe after the holidays and see what she has to say. I don't have the money for attorneys and all that stuff. I have spent every dime I have jumping through all of the hoops and now, I don't have anything left. I just want to have the surgery and get on with my life. Let me know how you approach your appeal.