Insurance Exclusions

[desperate 0]

I have researched the lap-band topic for a year and recently went to a free seminar. I want to move forward, but obesity surgery is excluded on my United Healthcare policy. Is there any hope? Can something be done and where do I start?

[kim2bhealthy 3]

Hello Desperate, and welcome to LBT! Exclusions are a tricky thing, and their are lots of people on this forum that can offer you help in this area.... The first thing that you need to do is look at your policy and see exactly what the exclusion says, and how it is worded... I just lost a several month long battle with my insurance company over their exclusion. It basically stated that "surgical treatment for obesity" is excludded. I tried to argue that I'm morbidly obese which is a different diagnosis from simple obesity, but they didn't go for it. I appealed twice to them and to my state's Department of Commerce and Insurance and lost... So I will be a self-payer. From what I've read, its almost impossible to beat an exclusion. Do you have co-morbidities such as sleep Apnea, High Blood Pressure, Diabetes, etc? Good Luck!

[desperate 0]

co-morbidities, lets see, depression, chronic headaches, Insomnia, RLS. Would those work? Not being sarcastic, just am lost at this point. I did not realize I wanted this so badly.

[desperate 0]

oh and the policy exclusion states "surgical treatments for obesity and morbid obesity"

[FunnyDuddies 6]

UHC is impossible to beat with their exclusions. I hit the same wall. I have to go self pay down in mexico because of it. They are really good at writing their exclusions to make sure that nothing gets covered. And they don't even look at your letter if they see the exclusion. I do not mean to be a wet blanket, but just letting you know what they are like. Its hard, but if there is an exclusion on there, you are pretty much not going to get anything from them. Sorry for the bad news. if by some miracle you do figure out something with them, let me know! LOL

[desperate 0]

I figured I hit a wall. Weren't you afraid of having something done in mexico?

[kim2bhealthy 3]

I knew that I had an exclusion on my policy from the beginning, but I had to at least try to get the insurance to cover it... My surgery will cost $18,000, so I felt it was worth the few months delay waiting to hear from them and appealing.. All I can say is its worth a try! Is self-pay an option? Is your insurance through a small business? I thought United was one of the better paying Insurance copmanies..

[desperate 0]

UH is suppose to be a better one at paying, but I work for an individual/small office. I am looking at trying to get an additional plan in place. Does anyone know if that works? Self pay is not an option at this time.

[urbrdfs 0]

Hi desperate,

Having surgery done in Mexico, once my mind was made up, was a breeze. They meet you at the airport (San Diego) and drive you across the border (so that take care of all the official things), pick you up a couple days after the surgery and take you to the hotel and the next morning pick you back up and take you back to the airport. Basdically all you have to do is "show up". The hospital I went to was cleaner than most I have been to in the US. The only problem I had was the language, however, they give you a sheet with basic words (English/Spanish) and you simply point to them, they are very good at interrupting. I found all of the staff to be so accommodating; they wanted to please and make us comfortable. I would not hesitate to go back to have additional surgery done.

iwa0r

[FunnyDuddies 6]

getting an additional plan is tough. most of the places you go to are not going to let you pick up additional coverage because you are over weight. UHC does not offer additional coverage on their policies.

As for the Mexico idea, at first I thought people were insane going to Mexico for surgery. But after a lot of studying and research I am comfortable with my choice. I am having my surgery done by one of the first surgeons to offer the Lap Band in the world, he has done over 5000 of the surgeries, has a low erosion and slippage rate, and works out of an American owned hospital in one of the richest cities in Mexico. The hospital itself is nicer than most hospitals here in america. Plus I get to recover at a guest house with a nurse on staff rather than in a hotel room by myself. It is just much more than I would get in america, but for half the price. I get everything, included the guest house and plane ticket, for $9100. That beats the $18k I would pay here in Tampa.

[dianas1 0]

I am sorry to say if there is an exclusion on your plan there is nothing you can do with that insurance company. If you try a new insurance they may also have the exclusion or require you to be a member for at least a year before they will consider authorizing the surgery. For people who are in this situation, there are companies that finance health care. I know that Capital One has a medical finance division and if you have decent credit they can finance the surgery for you for up to 6 years. They seem to have some decent interest rates. There are also other companies like,

http://www.vabfn.com/ ,

http://www.capitalonehealthcarefinance.com/?Web_Ad_Code=Q4051kL_stal_cofhc05_Sear_txtl_NH25_Gooron473xx_aa ,

http://www.reliancemedicalfinance.com/

The second one is capital one. Maybe you can speak to someone at each of these companies and see if they can help.

I too had an exclusion on my health plan and that is why I know these places exist. Hope that helped. Good luck, Di

[kdsmiles 0]

I just wanted to clarify something that some may not know....

UHC usually is the best insurance to deal with regarding any WLS...

The plans which have exclusions are not because UHC made that decision. It is because the EMPLOYER has chosen not to cover WLS...

I switched jobs when I found out the new job had UHC. Because I went to several seminars and heard nothing but the best about UHC covering WLS...

Talk about disappointing, when I finally got my new insurance with the new job. I waited 30days as the surgeon recommended, only to find out it was an exclusion on my policy...I also tried to fight it, but was told by an Executive at my company and UHC that the EMPLOYER sits down with UHC and makes a policy for it's employee's and chooses what will be covered and what will not....I was devastated and couldn't believe out of all the UHC policies, mine would have to be one that WLS was an exclusion. So I started another mission...To find another job in which WLS was covered before I accepted the job....Very tricky to do, since I didn't want the employer to know what my long term goal was, but I did it....

I am happy to say I started another new job and this insurance is also UHC, but the difference....WLS is covered when medically neceassary....

Fortunately, I am an RN and am able to have my choice of jobs since there is such a shortage of nurses. It was a pain to find out if the surgery was covered before I took the job, but I did it. All insurances need to treat this like the disease that it is and cover it all....

I just started my job March 27, 2006, needless to say, I have a ways to go before getting the surgery, but I am happy that my insurance does cover it. I will be able to have it at the hospital I work at here in Florida...I have done all my homework on this surgeon and have started the ball rolling as much as I can until I can go full force.

My advice is don't try and appeal it. I know many who have and unfortunately they wasted their time.

Before I switched jobs I too was looking at going to Mexico. It is true that there are several surgeon's who have been doing the bands longer than many here in the States...It is much cheaper and they can help you with financing too....Maybe you can look into it and see for yourself. They have coordinators you can talk to here in the States. They were very helpful to me and could help ease your mind....Best of luck to you, Kelli

[korkey 0]

getting an additional plan is tough. most of the places you go to are not going to let you pick up additional coverage because you are over weight. UHC does not offer additional coverage on their policies.

As for the Mexico idea, at first I thought people were insane going to Mexico for surgery. But after a lot of studying and research I am comfortable with my choice. I am having my surgery done by one of the first surgeons to offer the Lap Band in the world, he has done over 5000 of the surgeries, has a low erosion and slippage rate, and works out of an American owned hospital in one of the richest cities in Mexico. The hospital itself is nicer than most hospitals here in america. Plus I get to recover at a guest house with a nurse on staff rather than in a hotel room by myself. It is just much more than I would get in america, but for half the price. I get everything, included the guest house and plane ticket, for $9100. That beats the $18k I would pay here in Tampa.

Hello, This is my first time on LBT. I am so glad this site is available. It is full of information. My husband and I are researching the costs and options for the lapband surgery. We both have to have it. Our health is deteriorating year by year. We have Cigna POS. I'm not sure if the surgery is covered, but we will call and find out.

FunnyDuddies, Can you tell me which Dr. you are using in Mexico? And what city in Mexico? We have been looking at Monterrey (sp?) with Dr. Rumbaut. He appears to have the very best reputation that we have found so far. If our insurance will not cover our surgery, this is probably going to be one of our options.

Thanks for the info!

korkey

[o2beslim 0]

I don't want to put a damper on things but I would think twice about self paying. I had my lapband surgery 4/27. I am very healthy with the exception of my weight. My medical clearance indicated I had no heart or other health issues. To make a long story short, my blood pressure went down during the surgery and they had a hard time bringing it back up. I was in recovery for about 6 hours. It finally came back up and I am totally ok but I ended up spending the night in ICU. So far, the doctors and hospital have sent in claims amounting to almost $49,000. The hospital claim was $40,500. I'm sure there are more claims to come. I'm very nervous because I will have to pay 15% of whatever the insurance allows and right now I don't know how much that is. If I were self paying I would be in a panic. You just never know what could happen. However, regardless of how much I end up paying I am very excited about the future.

[walleyek 0]

I have Empire Blue Cross (BCBS of NY) and they cover Roux-en-y, but not Lap Band surgery. I'm completely comfortable having my Lap Band installed in Mexico by Dr. Rumbout, however I will have to get on a plane more than once to have my fills, because my state (and surrounding states) does not have a physician who's willing to take on a patient who had surgery in Mexico. Here was the reply from one of the prominent hospital systems in my state when I asked about follow-up care:

"It actually has not been very cost effective for our organization to do BAND fills on patients who have their BANDS placed in Mexico. Because the cost of the visit can be high (~$200-500 depending on what type of fill you receive), a lot of our patients had large outstanding balances with the hospital and some sent to collection. This and the large clinic volumes have made us reevaluate our practices."

BTW, I live in Minnesota.