Claim for surgery denied

[JGK88]

What is the name of your state? Pennsylvania.
My health insurance company has denied a pre-authorization claim for gastric bypass surgery stating that that type of surgery and all that goes with it is not included in the policy. I have since written and submitted the first appeal letter to the company.
I am a 43 year old "morbidly obese" female. I meet all the criteria for having this surgery performed; 100 lbs. overweight, have tried everything possible, asthmatic, muscle and joint pain, shortness of breath upon overexertion, unable to properly perform my job duties without extra assistance, etc.
Am I trying to win a losing battle with my insurance company? Can I throw the Americans with Disabilities Act to them since I do fall into the category of not being to live the quality of life I should?

 

[Beth3]

Sorry but the ADA has nothing to do with whether the insurance company is obligated to pay for this surgery. It depends entirely upon the language in the plan document/insurance booklet which outlines the coverage limits. If it specifically lists any and all treatments for obesity in the exclusions section or specifically lists gastric by-pass surgery due to obesity, then I'm afraid you're most probably out of luck.

If it doesn't specifically exclude these things or has language that is open for interpretation, then you have absolutely nothing to lose by appealing their decision. If they deny your appeal, then your next step would be to appeal to your State's Insurance Commission or whatever they call it in PA.

 

[CIAA]

JGK88,

I'm sorry for your difficult situation. Of course the ADA requires your employer to make "reasonable" accomodations, but the insurance issue is a seperate matter.

If it is coverage thru your employer (and I suspect it is), the Dept. of Insurance won't be able to help. Regulatory and enforcement authority for employer sponsored plans lies with the Dept. of Labor.

The denial of gastric surgery in these types of cases most often goes to the question of "medical necessity" and whether or not the treatment is "curative" of a disease process.

Based on our experience, if the obesity is "exogeonous" ( not caused by a disease process or pathology) then treatment is not for a "disease" and the insurance company will ask about "co-morbidities";that is, other diseases that cannot be effectively treated or controlled in the presence of the obesity. These most often include such things as uncontoled diabetes or blood pressure, severe debilitating arthritis, congestive heart failure, etc.

Some companies may allow for surgery in the absence of serious co-morbidities but they will usually require that you go thru a current medically supervised weight program first.

Hope this helps