Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 > I had asked to see a copy of the policy itself that > showed that and was told all they can do is send a > letter. I want to see the actual policy language - is > that asking for too much? > So, can I still fight this if it's correct that > intestinal bypass isn't covered? --------------------------------------------------------------------------------\ --------------------------------------------------------------- Dee, I asked for a copy of my certificate (from Cigna HMO) and was promptly mailed the full booklet ... you most certainly have a right to receive a copy of your policy, and I wouldn't take their excuse ... call back and get a manager or someone in a more authoritative position. I found in my policy ... after the exclusions list ... a 'waiver' of sorts that basically states that they (Cigna) can overturn anything in the policy (exclusions included), but that if they do this, it doesn't negate the rest of the certificate ... blah blah blah. You need to find out if there is anything like this in yours. At that point, if you can afford it, you may want to consider legal counsel with Walter Lindstrom as he has a fairly high success rate at overturning denials. I think it is tooooo soon for you to accept what your company is telling you ... the fight is just now starting, so get strong and demand what you're entitled to. Bye, Donna P.S. You can e-mail Walter at walter@... to see what he would suggest .... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Typical insurance BS!! Take it to the next level girl!! If they cover treatment for wt loss you have hope!! Open DS surgery will cost relatively the same amt as Lap RNY---so keep battling. They do intestinal bypass on the RNY too, what morons!! Pammi Denial Notice Ohmygosh, thank you all so much for the encouranging posts about my having doubts regarding the DS. I was having a weak moment, doubting myself, and there you were to pick me up. Dammit, this is not a cosmetic type surgery and we do deserve the best - not the cheapest - way to lose weight. By the way, I received a note from Pacificare that says: Intestinal bypass surgery is not a covered benefit on your plan. I had asked to see a copy of the policy itself that showed that and was told all they can do is send a letter. I want to see the actual policy language - is that asking for too much? So, can I still fight this if it's correct that intestinal bypass isn't covered? Thanks again, ===== Dee Waiting for Ins. Co. Approval 313/Want to be 165 __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Dee, I have Pacificare also and I found that Weight Loss Surgery was covered only when it met the National Institute of Health requirements. You can find thoes requirements by going to http://www.nhlbi.nih.gov/guidelines/obesity/sum_clin.htm these guidelines identify all the items that doctors should look for before recommending WLS. Read your policy carefully, because mine went on for a couple of paragraphes about what it would not cover in regards to weight loss. But the very last line was the exception I needed. I live in California and your state may be different. Also, PacifiCare denied me a counsultation for surgery. I sent copies of my Sleep Apnea Tests and Diet History, and I am waiting for a response. I was denied for the RNY before and I did not fight because I had decided that I wanted the DS. Now I am fighting. karon. 5.6 " 330lbs also wanting 165 > Ohmygosh, thank you all so much for the encouranging > posts about my having doubts regarding the DS. I was > having a weak moment, doubting myself, and there you > were to pick me up. Dammit, this is not a cosmetic > type surgery and we do deserve the best - not the > cheapest - way to lose weight. > > By the way, I received a note from Pacificare that > says: Intestinal bypass surgery is not a covered > benefit on your plan. > > I had asked to see a copy of the policy itself that > showed that and was told all they can do is send a > letter. I want to see the actual policy language - is > that asking for too much? > > So, can I still fight this if it's correct that > intestinal bypass isn't covered? > > Thanks again, > > ===== > Dee > Waiting for Ins. Co. Approval > 313/Want to be 165 > > __________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Take it to the next level girl!! If they cover treatment for wt loss you have hope!! Open DS surgery will cost relatively the same amt as Lap RNY---so keep battling. They do intestinal bypass on the RNY too, what morons!! ================================================================================\ =========== Pammi, Is it true that the open DS is close to the lap RNY ?? This is good to know ... based on the way they (insurance) act, I would've thought we'd be talking THOUSANDS !!!!! Bye, Donna Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 --- kronwright@... wrote: > Dee, I have Pacificare also and I found that Weight > Loss Surgery was covered only when it met the National Institute of Health requirements. You can find thoes requirements by going to > http://www.nhlbi.nih.gov/guidelines/obesity/sum_clin.htm These guidelines identify all the items that doctors > should look for before recommending WLS ****************** Hi, I'm in California too. I checked the NIH site and I definitely qualify with a 54 BMI. Actually Pacificare will cover the RNY but I feel the DS is the way to go due to the quality of life after surgery. Good luck to you and thanks! dee __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Jerry, I welcome the policy! I don't care if it's a book or not - LOL Actually, in my previous life (before becoming injured on the job), I was an insurance underwriter. No, I did NOT work for health care so please do not flame me! I am/was a commercial property, general liability, and auto underwriter. So reading a policy doesn't scare me! dee --- Jerry Cook wrote: > You are within your rights to demand a copy of your > policy! You usually > will get a BOOK with ALOT of " legal terms " but you > can make out what the > limits and exclusions are. Sometimes, however, you > are also able to find > loopholes!! Make em give you a copy of your policy, > a policy booklet or > something...DON'T LET EM SEE YOU SWEAT!! > HUGS TO A FELLOW WLS SISTER > JERRY, Southern gal from Louisiana > > > > > >Reply-To: duodenalswitch > >To: DS PacificLap > <DS_PacificLaparoscopy >, DS Switch > ><duodenalswitch > > >Subject: Denial Notice > >Date: Thu, 30 Aug 2001 08:14:57 -0700 (PDT) > > > >Ohmygosh, thank you all so much for the > encouranging > >posts about my having doubts regarding the DS. I > was > >having a weak moment, doubting myself, and there > you > >were to pick me up. Dammit, this is not a cosmetic > >type surgery and we do deserve the best - not the > >cheapest - way to lose weight. > > > >By the way, I received a note from Pacificare that > >says: Intestinal bypass surgery is not a covered > >benefit on your plan. > > > >I had asked to see a copy of the policy itself that > >showed that and was told all they can do is send a > >letter. I want to see the actual policy language - > is > >that asking for too much? > > > >So, can I still fight this if it's correct that > >intestinal bypass isn't covered? > > > >Thanks again, > > > >===== > >Dee > >Waiting for Ins. Co. Approval > >313/Want to be 165 > > > >__________________________________________________ > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 What REALLY gets me are the WLS doctors who want us to lose 10% of our body weight prior to WLS. >>>>> for some, its becuz of the possibility of abdominal compartment syndrome which is what happened to Joe Frost. Its not that they want to " punish you " ........ Judie Re: Denial Notice > --- Jerry Cook wrote: > > Hey Dee, > In a former life, before childbirth over 20 years ago > I worked for ........uuuummmmmm.....{Blue > Cross}(whisper)...as a claims processor...just don't > tell anyone!!! > ******* > Do ya think anyone saw our posts? hehehe Well, I > don't feel so bad, at least I didn't work in claims! > (Just kidding!) > > Sometimes I'd rather say I'm a used car saleswoman or > life insurance saleswoman than work for an insurance > company! LOL > > As for the hoops we must go through, it's so > ridiculous. Like we haven't already tried every diet > out there already! What REALLY gets me are the WLS > doctors who want us to lose 10% of our body weight > prior to WLS. Why punish us one last time before > surgery? > > dee > > > > ===== > Dee > Waiting for Ins. Co. Approval > 313/Want to be 165 > > __________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Wow, the talent in this Group! Deanna, thank you so much for the offer. My doc is trying one more time to get the DS. If it fails, I'll definitely let you know! And congrats on 197!!!!! I remember MANY years ago being about that weight and being depressed - I'd be THRILLED now! dee --- True's wrote: > Dear Dee, > I am a credentialed medical insurance mediator who > is getting pretty dang > good at helping ds'ers fight for surgery. If I can > help you let me know!!!! > Deanna > 300lbs bmi 50 day of surgery 02-15-01 > 197lbs. bmi 31 as I sit here now! > THANKS GOD !!!! > http://www.duodenalswitch.com/Patients/Deanna/deanna.html > > Denial Notice > > > >Date: Thu, 30 Aug 2001 08:14:57 -0700 (PDT) > > > > > > > >Ohmygosh, thank you all so much for the > > > encouranging > > > >posts about my having doubts regarding the DS. > I > > > was > > > >having a weak moment, doubting myself, and > there > > > you > > > >were to pick me up. Dammit, this is not a > cosmetic > > > >type surgery and we do deserve the best - not > the > > > >cheapest - way to lose weight. > > > > > > > >By the way, I received a note from Pacificare > that > > > >says: Intestinal bypass surgery is not a > covered > > > >benefit on your plan. > > > > > > > >I had asked to see a copy of the policy itself > that > > > >showed that and was told all they can do is > send a > > > >letter. I want to see the actual policy > language - > > > is > > > >that asking for too much? > > > > > > > >So, can I still fight this if it's correct that > > > >intestinal bypass isn't covered? > > > > > > > >Thanks again, > > > > > > > >===== > > > >Dee > > > >Waiting for Ins. Co. Approval > > > >313/Want to be 165 > > > > > > > > >__________________________________________________ > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 Thanks for the info, Judie, I really did think they wanted to punish us... or tell us since we lost 10%, to try for 20%.. then 30%, etc. so we won't have the surgery! dee --- Judie Hensel wrote: > > for some, its becuz of the possibility of abdominal > compartment syndrome > which is what happened to Joe Frost. Its not that > they want to " punish > you " ........ > > Judie > > __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 30, 2001 Report Share Posted August 30, 2001 dee....I know of two ladies their docs asked for them to lose 20lbs (is all) and then right after they lost it, they got their surgery date. The surgeon was just so fearful of abdominal compartment syndrome that he refused to operate until they did...and they flew thru the surgery with no complications. Judie =) Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.