Question
What is the name of your state? KY
Has anyone had an exclusion of contract overturned by the Dept. of Insurance?
Answer
It doesn't seem likely but you could try providing a little more information (or, well, ANY information) about your situation...
Answer
I had a vertical banded gastric bypass in 1998. I am having a lot of problems with getting sick. I cant keep down meat, vegetables, fruit, etc. I have lost 3 molars from gastric fluids and I also have a lot of heartburn, which prompted me to go to the doctor in the first plact. He did a scope and found that I need revisional surgery to correct my problems. The only problem being is that my Insurance has any type or form of gastric bypass surgery excluded from our contract. It has already been denied as a "coverage denial" they know it is medically necessary but still wont cover it. I am in desperate need to be fixed, I am tired of being sick all the time.
Answer
If the initial surgery was not covered under your current policy or if they would have denied the surgery anything related is not eligible for benefits.
The same policy is used for cosmetic services if a person goes in for a cosmetic surgery and then develops complications most policies will reject as related to a non covered service.
Remember that insurance does not cover everything.
I am sorry that your sick but your appeal will probity be overturned. Also if you have not had the corrected surgery your are only appealing either pre authorization or what was quoted over the phone. Some insurance carriers will not accept an appeal until a claim has been denied.
The Department of Insurance will not tell the carrier to extend benefits that are excluded, remember that insurance does not cover everything. Unless it is a State or Federal requirement they offer gastric bypass benefits (and its not) then your surgery is going to be your responsibility.
I will say there is an exception to every rule and if you appeal to the insurance carrier they may extend benefits, but do not rely on this. You have a better chance if this is a employer sponsored health plan as they are paying the money for the claims and sometimes pay for anything with the right story.
I cant stress this enough Remember that insurance does not cover everything.
Answer
There is a mistaken belief that an insurance policy is required to cover anything that your doctor says is medically necessary. There is no truth to that belief. Medically necessary or not, if a procedure is listed in the policy as being excluded, then they have no legal obligation to pay that that procedure whether it can be confirmed as medically necessary or not.