Newbie question about exclusions

educ8or2000 · February 12, 2008

Hi all,

I'm a newbie here....been interested in lapband for a couple of years, but no luck. Doctors say I qualify but it's listed as an exclusion on our insurance policy. We have BCBS and we live in Ohio.

Is there anything I can do now? I want to fight it...but I need to know where to start.

Thanks!

Maya314 · February 12, 2008

Hi all,
I'm a newbie here....been interested in lapband for a couple of years, but no luck. Doctors say I qualify but it's listed as an exclusion on our insurance policy. We have BCBS and we live in Ohio.

Is there anything I can do now? I want to fight it...but I need to know where to start.

Thanks!

Have you already been denied by your insurance?

destiny79 · February 12, 2008

ask your job to add it to the policy

educ8or2000 · February 13, 2008

I was denied 2 years ago. I didn't know what else to do, so the battle stopped there. I asked the insurance company and all they said was that it was an exclusion.

As far as asking my company, I'm actually on the insurance committee so it's been mentioned by me and another member. I work for a small school district with only about 250 insured employees, plus family members. The response I got was pretty much ignoring the fact and moving on. When I mentioned it again, our agent said that "most companies are not covering it anymore..."x" just stopped covering it and "y" will not after..."

I don't know enough about it, but I do know there are 100s of people getting it done and their insurance pays...I wanna be one of them!

What do I do now? Where do I go? Who do I talk to?

Thanks!

QTkidsmom · February 13, 2008

I believe that they are misinformed about plans removing coverage from the policies, it is actually being approved by more and more as time goes on. Before too long, I expect it to be the new "gold standard" and knock RNY off the top. The stats are better at 2-5 years and the insurance carriers are noticing.

CajunDisney · February 13, 2008

Other than becoming self-pay, are there any other options or ways to fight it?

What about state laws prohibiting insurance companies from denying a claim due to medical reasons? Is this really true...even if there are exclusions?

Maya314 · February 13, 2008

Other than becoming self-pay, are there any other options or ways to fight it?
What about state laws prohibiting insurance companies from denying a claim due to medical reasons? Is this really true...even if there are exclusions?

As your insurance company how you can appeal their decision, Now mind you.. you will have to be prepared to have an excellent letter of medical necessity from your Dr as well as Medical records backing you up but it can be done. Do you have any co-morbidities? That's always an issue too.

Good Luck.

runningagain · February 13, 2008

I agree with Maya314. Defenitely try to appeal it or get a letter of medical necessity/medical records. Co-morbidities may make the difference. My aunt had RNY 2 1/2 years ago and when she called the insurance company they said they currently didn't cover it, but might a year down the road. Well, she submitted her app. anyway and it went right through. As a matter of fact, she didn't have to wait your typical 6 months, her surgery was 2 months later!!

sharona · February 13, 2008

well if isn't in your policy that pretty much is it. You can obtain a benefit that was included in your policy to begin with. You could look at getting that benefit and asking what that would cost. I think that is your only option. I used to work in the insurance industry and they are very clear you get what your covered for and if there is an exclusion that's pretty much written in stone.

sharon:)