Is there anyway to get around exclusions in your insurance policy?

Question

I have United Healthcare and my particular policy excludes any surgery for obesity. I was hoping to have the bypass done, but since it is excluded.... I would have to pay for it out of pocket, and I cant afford that. I barely make enough to make my bills, none the less add a surgery. Can anyone tell me if they make exceptions to exclusions? Or is there a way to get around them? I really need this surgery if I want to be alive in another 10-15 years. I am submitting a letter of medical necessity from my doctor and a bariatric surgeon. I am can show a family history of comorbidities. I dont have any comobidites yet, but I will soon. My a1c is on the high end of normal. And my cholesterol is normal... but my ldl is on the high end of normal. I am getting a sleep study done to prove I have sleep apnea... but I dont know what else I can do. Any suggestions?

And in advance to those that will say go on a diet... I have been on dr supervised diets with no sucess.

I also know for a fact that they do cover this procedure on other policies. I have a friend who has UHC that had it done a year ago in March. Her coverage did not exclude it. So I know they do cover it if you have a certain policy. However, when I spoke with the guy who sold our company the insurance, he explained to me that exclusions are chosen by the company that buys the policy... which would be my employer. And while they were trying to keep down costs, they excluded it because since I work at a gym everyone else, besides me, is thin. So they never expected to have to use it... so why pay for coverage that they will never need? And while I understand that.. it is too late to change the policy... because then it would be a preexsisting condition... and still not covered.

Answer 1

For the most part, no, a flat out exclusion won't be covered. You can appeal it, and you're doing the right stuff - with the letter of medical necessity from two physicians. So if there's ANY chance they'll do it, that's what you need to do - AND, include a letter from the doctor who supervised the diets, too.

But the problem is, there are some procedures that insurance companies just haven't factored into their rates - and that's one of them. And if they make exceptions for exclusions for one person, then legally a court will make them make exceptions for EVERYONE, and poof, there goes the exclusion. And the rates triple for everyone.

If you really think you only have 10 years left without this surgery, well, if it was me, I'd jump through hoops to find an alternative to the surgery that could lead to weight loss.

Answer 2

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Answer 3

No, you will not get around this exclusion. The insurance company has the exclusion for such coverage in order to keep premium costs lower. The fact that you may truly need this surgery medically will not override their exclusion. By the way United Healthcare is far from the only one including such an exclusion. Gastric bypass surgery is an expensive procedure. Even those insurers which will cover it will require that you use other means to attempt weight loss for a lengthy period before they will pay for the procedure.

Answer 4

Hiya:

I believe this is going to end up being a covered surgery (at physician's direction) down the road.

Why?

It ultimately saves them money! The chances that you are going to need blood pressure medication, diabetes medication and supplies and other obesity related items will go down SIGNIFICANTLY over the period of your life if you have the surgery and successfully maintain a healthy weight. The information out there already proves that.

I think you have all the information you need. I know for a fact that they can and have covered this surgery. If they deny you the first time you can make an appeal with all of your information.

They may, and rightfully so, approve OTHER weight loss options to exhaust other available treatments before they would authorize the surgery - but like I said - they can and HAVE approved it before.

If they do NOT approve you - you may have legal recourse against them for failing to authorize a life saving surgery as prescribed by your treating physician especially in light of the fact that they have approved it in the past.

Goodluck to you!

~jifr!

Answer 5

Apply for county assistance. Most people can quailfy for some variation of either medicaid or county insurance-if your county offers it. That will help just incase UHC doesnt budge-which the chances of that happening are slim. Keep trying though because you are doing all the right steps. Also, call the insurance company and ask if your doctor can do a peer-to-peer review with their medical director. It may help.

Answer 6

Make pancakes even healthier by building mashed baked sweet potato, some pureed spinach and blueberries, or even cooked quinoa.

Answer 7

Walk day-to-day 35 mins in the morning

Answer 8

1. Try to get diagnosed with "morbid obesity". They may consider this to be a different condition from regular "obesity".
2. Get a different insurance policy, one without this exclusion.

Answer 9

They probably won't cover it, but you can try. Just get your doctor to request for authorization. After they deny it, make an appeal (in writing, do not do it over the phone) and submit all your documentation showing medical necessity.

Answer 10

It is my understanding that exclusions are just that and are not negotiable. If they negotiate for you on this, then their entire policy and exclusions would have to be negotiated for everyone.