INSURANCE EXLUSIONS - Dreamscape and Cathy in Lenoir

[Guest guest]

In a message dated 7/22/2000 6:40:36 PM Eastern Daylight Time,

lindat@... writes:

<< When " weight loss surgery is exluded " in your policy, there are a couple

of things to do:

>>

,

I appreciate your response. I have already typed out a letter

requesting the info on the general exclusion, but I hadn't thought of sending

it certified. I will do that. the paperwork my husband has on this policy

doesn't even mention " morbid obesity " it just says: Services which are not

medically necessary or medically appropriate, All expenses related to

physical conditioning programs, acupuncture, weight loss programs,

treatments, surgeries or modification therapies. Then the letter they sent me

says: United Healthcare of NC received a letter from Dr. Rutledge requesting

authorization of a Laparoscopic gastric Bypass due to morbid obesity. As

documented in the enclosed General Exclusion (there was nothing in the

envelope but the letter) from Bernhardt Furniture Group Medical Plan, obesity

treatment is specifically excluded from coverage. Therefore, United

Healthcare of NC is unable to authorize the services. (Second Paragraph)

Please note, as approved by the NC Dept. of Insurance, that the grievance

process does not apply to grievances based solely on the fact that United

Healthcare of NC does not provide benefits for the health care service in

question. United Healthcare of NC is unable to consider an appeal request for

these services.

It's signed by someone who says they are the Appeal & Grievance Coordinator.

It's the second paragraph that I just don't understand. I'm just kinda at a

loss and I'm not sure if I can appeal this. Thanks for your help, I really

appreciate that you replied to my former post!!!

Cathy in Lenoir, NC

Pre-op

BMI 42

A journey of a thousand miles begins with a single step

[Guest guest]

I'm working on posting an insurance primer tonight or tomorrow. Hope

that will help.

When " weight loss surgery is exluded " in your policy, there are a couple

of things to do:

(1) Make them prove it. Send a certified letter to them, asking them

to send you exactly the part that says weight loss surgery is excluded,

why, and under what conditions. Pick up the forms for the certified

letter at the post office ahead of time and at the top of the letter,

prominently write: " BY CERTIFIED U.S. MAIL #___________________ " (put

the number from the receipt in the letter). This will cost you about

$2.55 to mail, but it puts them on notice that you want proof and it

proves they got it (insurance companies like to claim they " didn't get "

things.)

It is possible that weight loss surgery is exluded *EXCEPT FOR* certain

cases and usually, the certain cases are " morbid obesity " and obesity

with life-threatening complications. Most everybody on here qualifies

under those " except for " conditions.

So don't take their word for it. It is just some insurance clerk

probably fresh out of high school sending you that letter and she may

not know any better.

(2) See if the hospital bill and anaesthesia are covered anyway.

Sometimes, even though the surgery itself ( " weight loss surgery " ) is

exluded, when you have to be hospitalized, your insurance policy will

cover the hospital bill and maybe even the anesthesia bill. This is the

*major* part of the expense. The surgery bill is $4,000 (and you get a

discount if you pay cash, so I think it is $3,200 in that case), but the

hospital bill is about $9,000 and the anesthesia is another $1,000. If

your policy pays the hospitalization, alone, that would be $9,000 you

don't have to pay. Again, find out if your policy will cover the

hospital bills. Just like they will pay for your physical before

surgery and medicines that you need after the surgery, they may very

well pay the hospital bill and even the anesthesia bill, even when

" weight loss surgery " is excluded in your policy.

Kind regards,

P.S. Since some of the newer folks may not know this, I'm an attorney

and I've had the MGB. There are seven attorneys that I know of who have

had the MGB.

CMo6331945@... wrote:

>

> In a message dated 7/22/2000 2:27:21 PM Eastern Daylight Time,

> dreamscape3@... writes:

>

> << " The CIGNA HealthCare of North Carolina, Inc., Health Services

> Department, has received a reques on you behalf for Gastric Bypass

> Surgery.

> After careful review of the information submitted, it has been

> determined

> that this request is denied because this is not covered under your

> group

> health benefit plan (see Member Certificate page 18, Item " KK " ). >>

>

> Hi Irene,

> You must be my twin!!! I'm also 5 feet tall, weigh 216 lbs.,

> have BMI

> of 42. My Insurance, United Healthcare of NC also denied me as saying

> there

> is an exclusion for " weight loss surgery " . The difference is my letter

> told

> me I can't appeal it which I don't understand. I thought all Insurance

> co.

> had an appeal process, so I am now at a loss at what I'm supposed to

> do. I

> guess try and save up the money to self pay, unless there is someone

> out here

> who can advise me on a different recourse. I wish you luck on fighting

>

> them!!!!!!!!!

[Guest guest]

Yours looks pretty bad. The exclusion is specific:

" all expenses related to . . . weight loss . . . surgeries. "

However, that does not rule out the payment of the hospital bill for a

necessary hospitalization, even if the surgery isn't covered. The

treatment is medically necessary, even if weight loss surgery is an

exclusion, so therefore, you can argue that the hospitalization is a

necessary hospitalization and should be covered.

> As documented in the enclosed General Exclusion (there was nothing in the

> envelope but the letter) from Bernhardt Furniture Group Medical Plan,

> obesity treatment is specifically excluded from coverage.

Make them send it to you.

> Please note, as approved by the NC Dept. of Insurance, that the

> grievance process does not apply to grievances based solely on the fact that

> United Healthcare of NC does not provide benefits for the health care service

> in question. United Healthcare of NC is unable to consider an appeal

> request for these services. It's signed by someone who says they are the

Appeal & Grievance

> Coordinator.

> It's the second paragraph that I just don't understand. I'm just kinda

> at a loss and I'm not sure if I can appeal this. Thanks for your help, I

> really appreciate that you replied to my former post!!!

Insurance is a contract between you and the insurance company (or your

husband's employer and the insurance company, with you being a

third-party beneficiary of the contract).

As the law sees it, parties to a contract are always free to negotiate

the terms of a contract, or to walk away from it (turn it down) if the

terms don't suit them.

(Now, I know that is not the practical reality of insurance coverage

through your husband's employer but that's how the law sees it).

So, when the parties aree " negotiating " the terms of the contract, they

can decide to exclude certain things from coverage. The other side

doesn't have to take the contract if they don't like the terms.

So when there is a specific " exclusion " in your policy, it is actually a

condition of the insurance contract itself. It is not something that is

appealable because it was written into the contract.

Issues that can be appealed are things like when the insurance company

says " Yes, that surgery is covered in the policy but you don't qualify

because it isn't medically necessary in your case. " In that case, you

appeal and prove it is medically necessary in your case. In otherwords,

the insurance company has the discretion to decide if you do or do not

qualify for coverage for a procedure that is covered in the policy.

But in the case of an exclusion, the insurance company has no

discretion. The type of surgery itself is specifically not included in

the contract, no matter what your good reasons for having it may be.

But as I said, the insurance *may* still cover the hospitalization for

the surgery. Can't hurt to check.

Now to pursue this, you have to insist that only the surgery is

excluded, and that hospitalization is *specifically* included in your

policy (quote the relevant parts of the policy) when it is medically

necessary. Even though surgery for weight loss is excluded, that does

not mean it isn't medically necessary, so you want to argue with them

that a hospitalization for that surgery would be " medically necessary "

and covered (maybe). I hope this makes sense.

Kind regards,

>

> Cathy in Lenoir, NC

> Pre-op

> BMI 42

> A journey of a thousand miles begins with a single step

> ----------------------------------------------------------------------

>

> ----------------------------------------------------------------------

> This message is from the Mini-Gastric Bypass Mailing List at

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> Please visit our web site at http://clos.net

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>

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[Guest guest]

Ditto to 's post. Also remember that " exclusions " take many forms and

may not be enforceable depending on the precise language of the exclusion

(there are differences between " weight control " " obesity " " morbid obesity "

etc.) and these exclusions do not generally ever address co-morbidities.

Some exclusions address " procedures " such as " gastric stapling, " " intestinal

bypass " etc. and the company's use of archaic language may be of assistance

in defeating these as well. Other " exclusions " aren't exclusions at all,

but rather a purported failure to establish " medical necessity " in

accordance with Medical Policy Criteria that is separate from the policy.

There are several articles published on the below cite which may help you

with these issues. Good luck.

Walter Lindstrom, Esquire

Obesity Law & Advocacy Center

www.obesitylaw.com

2939 Alta View Drive - Suite O-360

San Diego, CA 92139

Tel:

Fax:

INSURANCE EXLUSIONS - Dreamscape and Cathy in

Lenoir

> I'm working on posting an insurance primer tonight or tomorrow. Hope

> that will help.

>

> When " weight loss surgery is exluded " in your policy, there are a couple

> of things to do:

>

> (1) Make them prove it. Send a certified letter to them, asking them

> to send you exactly the part that says weight loss surgery is excluded,

> why, and under what conditions. Pick up the forms for the certified

> letter at the post office ahead of time and at the top of the letter,

> prominently write: " BY CERTIFIED U.S. MAIL #___________________ " (put

> the number from the receipt in the letter). This will cost you about

> $2.55 to mail, but it puts them on notice that you want proof and it

> proves they got it (insurance companies like to claim they " didn't get "

> things.)

>

> It is possible that weight loss surgery is exluded *EXCEPT FOR* certain

> cases and usually, the certain cases are " morbid obesity " and obesity

> with life-threatening complications. Most everybody on here qualifies

> under those " except for " conditions.

>

> So don't take their word for it. It is just some insurance clerk

> probably fresh out of high school sending you that letter and she may

> not know any better.

>

> (2) See if the hospital bill and anaesthesia are covered anyway.

> Sometimes, even though the surgery itself ( " weight loss surgery " ) is

> exluded, when you have to be hospitalized, your insurance policy will

> cover the hospital bill and maybe even the anesthesia bill. This is the

> *major* part of the expense. The surgery bill is $4,000 (and you get a

> discount if you pay cash, so I think it is $3,200 in that case), but the

> hospital bill is about $9,000 and the anesthesia is another $1,000. If

> your policy pays the hospitalization, alone, that would be $9,000 you

> don't have to pay. Again, find out if your policy will cover the

> hospital bills. Just like they will pay for your physical before

> surgery and medicines that you need after the surgery, they may very

> well pay the hospital bill and even the anesthesia bill, even when

> " weight loss surgery " is excluded in your policy.

>

>

> Kind regards,

>

>

>

> P.S. Since some of the newer folks may not know this, I'm an attorney

> and I've had the MGB. There are seven attorneys that I know of who have

> had the MGB.

>

>

> CMo6331945@... wrote:

> >

> > In a message dated 7/22/2000 2:27:21 PM Eastern Daylight Time,

> > dreamscape3@... writes:

> >

> > << " The CIGNA HealthCare of North Carolina, Inc., Health Services

> > Department, has received a reques on you behalf for Gastric Bypass

> > Surgery.

> > After careful review of the information submitted, it has been

> > determined

> > that this request is denied because this is not covered under your

> > group

> > health benefit plan (see Member Certificate page 18, Item " KK " ). >>

> >

> > Hi Irene,

> > You must be my twin!!! I'm also 5 feet tall, weigh 216 lbs.,

> > have BMI

> > of 42. My Insurance, United Healthcare of NC also denied me as saying

> > there

> > is an exclusion for " weight loss surgery " . The difference is my letter

> > told

> > me I can't appeal it which I don't understand. I thought all Insurance

> > co.

> > had an appeal process, so I am now at a loss at what I'm supposed to

> > do. I

> > guess try and save up the money to self pay, unless there is someone

> > out here

> > who can advise me on a different recourse. I wish you luck on fighting

> >

> > them!!!!!!!!!

>

> ------------------------------------------------------------------------

> Missing old school friends? Find them here:

> http://click.egroups.com/1/7079/3/_/453517/_/964305456/

> ------------------------------------------------------------------------

>

> This message is from the Mini-Gastric Bypass Mailing List at Onelist.com

> Please visit our web site at http://clos.net

> Get the Patient Manual at http://clos.net/get_patient_manual.htm

>

> To Unsubscribe Send and Email to:

MiniGastricBypass-unsubscribe (AT) egroups (DOT) com

>

>

>

[Guest guest]

It is an incorrect statement that exclusions cannot be appealled. They can

be appealled and, quite often, successfully defeated. Sometimes an

" exclusion " is not legally enforceable or simply does not apply to the case

at hand. For instance, diabetics or persons with severe reflux or sleep

apnea are often able to get surgery after an initial denial because the

surgery is not for " weight loss " but rather, as primary treatment for

comorbidities. There is caselaw we use which supports these and other

aspects of fighting insurance denials. Good luck in your situation.

Walter Lindstrom, Esquire

Obesity Law & Advocacy Center

www.obesitylaw.com

2939 Alta View Drive - Suite O-360

San Diego, CA 92139

Tel:

Fax:

Re: INSURANCE EXLUSIONS - Dreamscape and Cathy

in Lenoir

> Yours looks pretty bad. The exclusion is specific:

>

> " all expenses related to . . . weight loss . . . surgeries. "

>

> However, that does not rule out the payment of the hospital bill for a

> necessary hospitalization, even if the surgery isn't covered. The

> treatment is medically necessary, even if weight loss surgery is an

> exclusion, so therefore, you can argue that the hospitalization is a

> necessary hospitalization and should be covered.

>

> > As documented in the enclosed General Exclusion (there was nothing in

the

> > envelope but the letter) from Bernhardt Furniture Group Medical Plan,

> > obesity treatment is specifically excluded from coverage.

>

> Make them send it to you.

>

>

> > Please note, as approved by the NC Dept. of Insurance, that the

> > grievance process does not apply to grievances based solely on the fact

that

> > United Healthcare of NC does not provide benefits for the health care

service

> > in question. United Healthcare of NC is unable to consider an appeal

> > request for these services. It's signed by someone who says they are the

Appeal & Grievance

> > Coordinator.

>

> > It's the second paragraph that I just don't understand. I'm just kinda

> > at a loss and I'm not sure if I can appeal this. Thanks for your help, I

> > really appreciate that you replied to my former post!!!

>

> Insurance is a contract between you and the insurance company (or your

> husband's employer and the insurance company, with you being a

> third-party beneficiary of the contract).

>

> As the law sees it, parties to a contract are always free to negotiate

> the terms of a contract, or to walk away from it (turn it down) if the

> terms don't suit them.

>

> (Now, I know that is not the practical reality of insurance coverage

> through your husband's employer but that's how the law sees it).

>

> So, when the parties aree " negotiating " the terms of the contract, they

> can decide to exclude certain things from coverage. The other side

> doesn't have to take the contract if they don't like the terms.

>

> So when there is a specific " exclusion " in your policy, it is actually a

> condition of the insurance contract itself. It is not something that is

> appealable because it was written into the contract.

>

> Issues that can be appealed are things like when the insurance company

> says " Yes, that surgery is covered in the policy but you don't qualify

> because it isn't medically necessary in your case. " In that case, you

> appeal and prove it is medically necessary in your case. In otherwords,

> the insurance company has the discretion to decide if you do or do not

> qualify for coverage for a procedure that is covered in the policy.

>

> But in the case of an exclusion, the insurance company has no

> discretion. The type of surgery itself is specifically not included in

> the contract, no matter what your good reasons for having it may be.

>

> But as I said, the insurance *may* still cover the hospitalization for

> the surgery. Can't hurt to check.

>

> Now to pursue this, you have to insist that only the surgery is

> excluded, and that hospitalization is *specifically* included in your

> policy (quote the relevant parts of the policy) when it is medically

> necessary. Even though surgery for weight loss is excluded, that does

> not mean it isn't medically necessary, so you want to argue with them

> that a hospitalization for that surgery would be " medically necessary "

> and covered (maybe). I hope this makes sense.

>

> Kind regards,

>

>

>

>

>

>

> >

> > Cathy in Lenoir, NC

> > Pre-op

> > BMI 42

> > A journey of a thousand miles begins with a single step

> > ----------------------------------------------------------------------

> >

> > ----------------------------------------------------------------------

> > This message is from the Mini-Gastric Bypass Mailing List at

> > Onelist.com

> > Please visit our web site at http://clos.net

> > Get the Patient Manual at http://clos.net/get_patient_manual.htm

> >

> > To Unsubscribe Send and Email to:

> > MiniGastricBypass-unsubscribe (AT) egroups (DOT) com

>

> ------------------------------------------------------------------------

> Find long lost high school friends:

> http://click.egroups.com/1/7080/3/_/453517/_/964308345/

> ------------------------------------------------------------------------

>

> This message is from the Mini-Gastric Bypass Mailing List at Onelist.com

> Please visit our web site at http://clos.net

> Get the Patient Manual at http://clos.net/get_patient_manual.htm

>

> To Unsubscribe Send and Email to:

MiniGastricBypass-unsubscribe (AT) egroups (DOT) com

>

>