Ask Dr Nerenberg | Health and Fitness

Can you sue a health insurance company for denying medical coverage?

My doctor has referred me to have the gastric by-pass surgery. I’ve spent the last 4 months and countless money (of my own) getting all the things the done the insurance company has asked for. This includes psych evaluation, sleep study, nutrition counseling, physicals and documentation to include I have tried at least 2 non-surgical weight loss programs for over a year with no long term success. Finally after submitting everything, they denied me for “no recent active participation in a non-surgical weight reduction program”. My last weight loss attempt was a year ago. I am about to lose my job because I cannot literally stand up on my feet anymore. This is something I have to get, not something I just want. It would seem if both my primary physician and the specialist both agree this is medically necessary, then the insurance companies couldn’t deny someone their health.

Covering the gastric bypass and similar procedures is relatively new for insurances who have always lumped this with being cosmetic.
Most insurances are now starting to cover these procedures but they have criteria you must fall under and hoops you must jump through in order for you to be approved. Such as, being over a certain BMI for one. They expect that you have severe documented instances of knee/ankle/leg pain from walking and back pain that you have been treated for thus far.
Some do have criteria for having “failed” at some form of dieting/weight loss program and most require you to have been on this plan at least 3 to 6 months prior to having made your appeal.
Can you sue them for not approving you, you can try. The thing is that they will probably win. You can file a complaint with the Department of Insurance in your area, you can also complain to the Agency for Health Care Administration.
You can also try and have the decision overturned within the insurance. If you’re adamant about suing call an attorney nearby and see if he thinks you have a case.

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