How hard is it - ThinnerTimes

buffsrule76 · 11-18-2007, 07:06 PM

to appeal insurance?? i only ask because i explained my situation to the insurance person at the new clinic i was going to go through and she told me its nearly impossible because of the exclusion

Godsblessedme · 11-18-2007, 07:24 PM

if your insurance plan doesnt even have the benefit in thier plan i would tend to agree.

If it is in your plan you should be able to easily appeal and win. Thats what i did. The benefit is in my plan and i did all they required me to do and then they denied me. I appealed thier decision and won.

I encourage you to keep at it and dont let up for a minute! Best of luck with it.

Cinerbelle · 11-18-2007, 08:00 PM

See some of the attached Threads regarding this. I found these by using the "Search" button with the work "exclusion".

Anyone successfully fight an employer's exclusion?

Need help finding insurance?....

Direct exclusion

im crying my eyes out right now

Denied

As you can see, most people with a direct exclusion do not end up having the surgery covered. You will need to research your own insurance and put in the leg work to see what the end result will be.

buffsrule76 · 11-18-2007, 08:56 PM

Thank you very much

Lovetoday · 11-19-2007, 04:22 AM

Hi there, I work for a medical aid administrator( what we call them in SA)... and can tell you that the best ones are:
- Never write emotional letters ( these get ignored)
- Write factual letters
- give supporting research.
- Don't threaten to take your business elsewhere unless you are the director of a company with 1000 people insured through them.
If you have any co-morbitities- list these and their known complications- ie Heart attack , Cardiac Bypass surgery or amputations and Gangrene.

Ask the insurance company what their appeals process is- ours work that it goes higher every time you appeal.

Keep on going. Even if you are refused now, try again in three months time. Policies change all the time, what may be an exclusion today, may be approved tomorrow under appeal.

With so many insurance companies paying for it already, the pressure mounts on those that do not have it.

Cinerbelle · 11-19-2007, 05:44 PM

Quote:

Originally Posted by Lovetoday

Hi there, I work for a medical aid administrator( what we call them in SA)... and can tell you that the best ones are:
- Never write emotional letters ( these get ignored)
- Write factual letters
- give supporting research.
- Don't threaten to take your business elsewhere unless you are the director of a company with 1000 people insured through them.
If you have any co-morbitities- list these and their known complications- ie Heart attack , Cardiac Bypass surgery or amputations and Gangrene.

Ask the insurance company what their appeals process is- ours work that it goes higher every time you appeal.

Keep on going. Even if you are refused now, try again in three months time. Policies change all the time, what may be an exclusion today, may be approved tomorrow under appeal.

With so many insurance companies paying for it already, the pressure mounts on those that do not have it.

It's not his insurance that is excluding WLS...it is his employer....I have yet to see someone get the employers exclusion overturned. If there is anyone out there that has they should put their story under the insurance section so that others can see how they got approved.