Question:
Does exclusions take into account medical neccesity?
Written exclusion by UHC epo, policy funded by employer states "no benefits for surgical or non surgical treatment of obesity or morbid obesity. this is it! does not say anything about exclusion if medically proven necessary. has anyone else found this in their policy is medical neccesity not even taken into account? — manalden55 (posted on May 19, 2003)
May 19, 2003
Nope, It means that the company you work for is smart enough to buy a
"cheap" plan with an exclusion for this expensise surgery. It
won't look at medical necessity. You need a lawyer to fight exclusions. Try
Walter Lindstrom.
Good Luck!
— ZZ S.
May 19, 2003
With an exclusion, medical necessity doesn't even enter the picture; it
does not matter. Previous poster is correct. The only way to fight an
exclusion is through the legal system.
— koogy
May 19, 2003
Even Walter Lindstrom has started telling people that it will be a waste of
time to fight an exclusion like this. But it wouldn't hurt to try. Good
luck!!!
— Delores S.
May 19, 2003
I have UHC PPO and I have the same exclusion in my policy. What you need to
do first is find out who has the exclusion, your employer or UHC. In my
case UHC has the exclusion but when I called them to find out if I could
get around it they said they do it case by case and told me with my
co-morbities that there was a really good chance I would get approved. One
rep told me that at the top of the page of exclusions it states that any
procedure that is not medically necessary will be excluded and that is how
i can get around it. Give them a call and talk to them before you give up:)
good luck jeannie
— harleigh2002
May 20, 2003
You could ask if they have EVER granted this surgery on a policy with an
exclusion (and ask someone besides the customer service person answering
the phone - ask for a Nurse Case Manager or equivalent). But basically -
an exclusion is an exclusion.
Its like when you rent a car - you HAVE to be 25. If you rent a car and
let your teenager drive it and there is an accident, just FORGET insurance
covering it - you just bought yourself a crashed car.
— bethybb
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