Re: INSURANCE EXLUSIONS - Dreamscape and Cathy in Len...

[Guest guest]

..

..

For anyone who hasn't read the previous emails about this, we are

talking about a situation where weight loss surgery is specifically

excluded in an insurance policy with wording to the effect that " this

policy does not cover treatments and related expenses for weight loss

surgeries. "

CMo6331945@... wrote:

> Well, it kinda sounds like I'm up s**t creek without a paddle.

Maybe only on the *surgery* bill itself. That is $4,000 of the total (I

think it is $3,200 if you pay cash). The insurance may have to pay for

the hospital and anesthesia bill because those are *NOT* " treatments for

weight loss, " they are necessary expenses for a medically necessary

procedure. The insurance will argue that they are a " related expense, "

but you in rebuttal argue that the policy covers hospitalization for

necessary medical treatment.

Just because the surgery is an excluded procedure doesn't mean it isn't

medically necessary.

The fact that it is " excluded " is a contract issue, not a medical

issue. A procedure can be " excluded " in the contract, but still be

something you need, medically. Since you are morbidly obese, the

surgery is medically necessary, it is just excluded in your policy. So

you argue that the other expenses, the hospital and anesthesia, are

covered benefits for a medically necessary procedure.

And the hospitalization and the anesthesia obviously aren't " treatment

or surgery for weight loss, " or " related to " weight loss, they are

(probably) covered expenses for necessary medical treatment.

Most people do not know about or even know how to argue this issue so

they just figure " Oh, it's excluded, too bad for me, " and they either go

away or self-pay.

But if you push the issue, the insurance may have to pay $10,000 of that

$13,200 bill. It's definitely worth pushing the issue.

You really have several parts to your expenses and as you can see, some

of these expenses definitely will be covered and some of them *may* be

covered if you push it:

Physical, EKG, PAP test, mammogram, about $700 -- all probably

covered by insurance

Medicines you need, pre-op, $150 -- all probably covered by

insurance

Clinic Visit, $255 -- probably not covered by insurance

Anaesthesia, $1,000 -- May be covered by insurance if you push it

Surgeon's bill, $4,000 -- Will not be covered since it is excluded

in the policy

Hospital bill, about $9,000 -- May be covered by insurance if you

push it

Medicines you need post-op, about $300 -- all probably covered by

insurance

> I really appreciate your time and help and if I have to I will save and self

> pay. I want to and am going to have this surgery. I want my life back and I

> know this is the only way it's going to happen!!!!!! Again thanks for your

> help!!!!!!

Hope it does help, Cathy. It may not, but it can't hurt to try it.

Best wishes for a successful journey!!

Kind regards,

[Guest guest]

In a message dated 7/22/00 5:05:11 PM Pacific Daylight Time,

CMo6331945@... writes:

<< >>

Well, it kinda sounds like I'm up s**t creek without a paddle. I

really

appreciate your time and help and if I have to I will save and self pay. I

want to and am going to have this surgery. I want my life back and I know

this is the only way it's going to happen!!!!!! Again thanks for your

help!!!!!!

Cathy in Lenoir, NC

Pre-op

>>

Hi Cathy,

Don't give up, sweetie! Someone on the list said they took out a loan for

the surgery so they wouldn't have to wait to save up. Just a thought.

Regards,

Debbie in IL

Daughter MGB 8/9 Cigna (3rd appeal)--BMI 45

Counting on Cigna for Debbie (BMI 40) First request denied 7/21 :0(

[Guest guest]

In a message dated 07/23/2000 9:09:47 PM Eastern Daylight Time,

lindstromw@... writes:

<< There is caselaw we use which supports these and other

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

Walter Lindstrom, Esquire >>

Hi Mr Lindstrom,

It is nice of you to offer advise for those of us fighting for approval. Does

this mean you have changed your position on the MGB?

Sharon In KY

[Guest guest]

In a message dated 07/23/2000 9:09:47 PM Eastern Daylight Time,

lindstromw@... writes:

<< There is caselaw we use which supports these and other

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

Walter Lindstrom, Esquire >>

Hi Mr Lindstrom,

It is nice of you to offer advise for those of us fighting for approval. Does

this mean you have changed your position on the MGB?

Sharon In KY

[Guest guest]

At the risk of re-opening this can o' worms (something none of us wants I

suspect), my " position " is to continue the positive dialogue that Dr. R and

I are having in private so my education process continues but, as always, to

provide whatever I can to those who need generalized assistance so they can

also help themselves whereever possible. The perfect world will be,

someday, that attorneys are never necessary to getting approvals for any

procedure!

Walter Lindstrom, Esquire

Obesity Law & Advocacy Center

www.obesitylaw.com

2939 Alta View Drive - Suite O-360

San Diego, CA 92139

Tel:

Fax:

Re: Re: INSURANCE EXLUSIONS - Dreamscape and

Cathy in Len...

> In a message dated 07/23/2000 9:09:47 PM Eastern Daylight Time,

> lindstromw@... writes:

>

> << There is caselaw we use which supports these and other

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

> Walter Lindstrom, Esquire >>

>

>

> Hi Mr Lindstrom,

> It is nice of you to offer advise for those of us fighting for approval.

Does

> this mean you have changed your position on the MGB?

> Sharon In KY

>

>

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