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

	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. Asked By: CMS - 11/14/2006

Best Answer - Chosen by Asker
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. Answered By: NyteShayde - 11/14/2006

Additional Answers ()

They can and they have done it to other people. The treatment you are talking about is not 100?afe. Some people develop complication from it. Maybe that is why they reserve it as the last resort. It shouldn't be hard to participate in a non-surgical weight reduction program. After that, they may pay for the surgery. Good luck. Answered By: spot - 11/14/2006

Insurance companies are not required to cover this sort of procedure. You should familiarize yourself with your policy to see if they are lying to you but chances are that they are in the right. If you really feel that they are misleading you then you may want to see an attorney to help you review your policy and try to find a way to force the insurance to pay for the procedure. In conclusion, just because something is believed to be medically necessary does not immediately force an insurance company to pay for it. Answered By: Badstudent - 11/14/2006

You could sue, but it's easier to file a complaint with your state's insurance commissioner's office. It's free and they have access to contracted physicians who review the medical necessity of the procedure. In this case, it appears the specialist would also review the carrier's medical necessity guidelines to see if they're too stringent. Given the radical nature of this surgery, it doesn't sound outrageous to me that you'd be required to have participated in a recent weight loss program that's medically monitored and guided. I hope this helps. Answered By: Suzanne - 11/14/2006

You can sue anyone for anything, so the answer is yes. The cost of the lawyer might be A LOT, you'll have to pay that up front. If the contract (policy) specifies that they won't cover gastric by-pass - and a lot of them don't - then, well, they don't cover it! So you'll lose your suit. You really need to sit down and read the policy. AND you need to appeal their decision. Meanwhile, while you're waiting for the appeal, join up with TOPS or WW, go to the weekly meetings - because that IS active participation. The appeal will take weeks. Source(s): Agent, 20+ years Answered By: mbrcatz17 - 11/14/2006

Submit your answer or comment to this question

Other Career Questions

	Will bad credit prevent me from getting an insurance job in florida? I have been unemployed and my credit is not good. Will this prevent me from getting an insurance job and license in Florida? 3 answers - Asked By: Kathy G - 11/9/2012

	How to land a career in a insurance industry and make good money? How does insurance jobs work and what is a good insurance job. Can you be license insurance agent and sell Home, Auto, life and Health Insurance. Also how much a good insurance agent take home at the end of the month. 6 answers - Asked By: Zeeshan Ali - 4/4/2010

	What property and casualty insurance companies are in North Carolina, not including agent offices? My husband and I are looking to move to North Carolina and we don't have a specific city. We want to start looking for Property and Casualty insurance jobs that are in NC but we don't know what companies there are. We don't want to work for agent offices but hopefully for a larger company. Could someone please provide us with a list of companies? 1 answer - Asked By: jritchey29 - 5/5/2011


Content is not owned or controlled by Monster. Any content concerns should be addressed with Yahoo! Yahoo! Does not evaluate or guarantee the accuracy of any Yahoo! Answers content. Yahoo! Disclaimer.

Monster Communities

Teaching Community: Where teachers meet and learn.
ArtBistro: Create and connect.
Excelle: Networking for the career-minded woman.
Nursing Link: Where nurses call the shots.
More Monster Communities

Monster Partners

Scholarships: Scholarships, financial aid and more ways to pay for school.
Education.org: Find top campus and online degree programs.
Military.com: Military portal for the US Army, Navy, Air Force, Marine Corps and Coast Guard.
Financial Aid: Scholarships & financial aid.
Staffing for Government Jobs: Staffing and hiring solutions for federal government agency jobs.
More Monster Partners

Job Hunt Strategy

Six Ways to Make a Recruiter Hate You

If you want to blow your chances with recruiters -- and, by extension, with the companies they work for -- here are six perfect ways to do so.

Resumes & Cover Letters

Rev Up Your Resume to Relocate

Hoping to relocate? Get the ball rolling on landing the right job in the right location with these expert resume and cover letter tips.

Interviewing

100 Potential Interview Questions

Interview questions can run the gamut. You probably won't face all 100 of these, but you should still be prepared to answer at least some of them.

Salary & Benefits

10 Questions to Ask When Negotiating Salary

Most of us aren't natural negotiators, but asking these 10 questions during salary negotiations can help you get everything you deserve.

Attracting Candidates

Facebook for Employers: Make Friends, Not Fans

Recruiting? Go where the talent is. See why recruiters have befriended social networks.

Employee Sourcing

Employment Index

November Monster Employment Index Grows 13% Year-Over-Year, Tenth Consecutive Month of Positive Annual Growth.

Interviewing Candidates

Improving Interview Skills: Learn from the Experts

What’s the key to a great interview? According to experts: Practice, practice, practice.

Workforce Planning

Enhance your Small Business Marketing Strategy with Social Media

Social media. It’s everywhere. But how can it help you? Learn how to utilize social media even monetize it.

For Seekers

Campus and Online Degrees: Advance your career and earn more with an online degree.
Free Salary Wizard: What are you worth? Find out and negotiate a better salary.
Research Careers: Get information on jobs and career paths to help guide your choices
Questions & Answers: Find answers to all your career related questions -- powered by Yahoo! Answers
Resume Distribution Service: Our distribution service puts your resume right in the hands of recruiters.
Resume Writing Services: Our experts will craft a keyword-rich resume that stands out in the crowd.
More Career Resources

For Employers

Career Ad Network: Target your job posting to more candidates on thousands of websites.
Hire Right Background Checks: Explore our background check packages to improve the quality of your hires.
Hiring Home Page: Find the best candidates for your business with Monster hiring solutions.
Job Postings: Find the right solution for your hiring needs. Starting at $99.
Power Resume Search: Monster's new search technology precisely matches people with your jobs.
Resource Center: Find staffing insights, labor trends, HR best practices and more.
Target Post: Connect with skilled, hourly and administrative candidates for only $99.

Social Media

Jobs on Twitter: Find jobs in your area and industry.
Monster Careers: Tune into our career advice and discussions tackling a wide range of topics and industries.
Monster Corporate & PR: Stay up-to-date on the latest news. Get the 'Who', 'What', 'When', and 'Why' on all things Monster related.
Monster Customer Service: Got a Monster question? We've got the answer. Whether you're a job seeker or employer, we can help you find the answers you need.
Monster for Employers: Find advice on hiring.
Follow Us: Check out our many pages and stay connected with the latest industry news, events, career advice and job openings.

Are You An Employer?