When self-pay who pays for complications?

[brittu 42]

Hi all,

I'm just about to start my official fight with the insurance company (Fed BCBS) for denying coverage for revision to VSG after a lap band slip. I plan to have surgery with Dr. Aceves if I don't win on appeal and possibly if it looks like it's going to take too long (I've already gained back nearly half of the weight I lost). Here's my question...

I've read a few stories of VSGers who had a serious leak that required considerable hosptial time and medical care. This really concerns me when I think about self-pay - I assume this kind of care could run in the tens of thousands of dollars if not more. But who pays for this in the case of self-pay? Does the insurance refuse coverage?

Thanks!

Britt

[burnsun 27]

my insurance paid for certain things...... the hospitalization, the anesthia and the dr except for the actual surgeon fees (4 k billed to insurance.....requied to pay 2850 ....the part insurance would have paid him) or his little followers fees unless it was hospital visit. I also had to pay my deductible 1500$ but my whole hospital stay was well over 100K ....I also had an emergency c-section too caused by the lap band issue and need for surgery......the covered all this too!

[Elisabethsew 50]

I believe any complications from VSG surgery done in Mexico are treated and covered by insurance in the U.S. If you have a leak while in Mexico, it is treated there. Dr. Aceves has done over 600 sleeves and has no leaks.

[burnsun 27]

My policy here now reads no expenses to to any type of bariatric surgery (revision or fixes included). we have lost three appeals on getting them to pay for the parts they would not cover.....we even asked for the part i paid to come off the individual and family deductible....no luck.

Our state insurance commission said if they exclude bariatric surgert....they can exclude whatever the deem related to it.....in our case what came down to life saving for the baby they paid for.....because of our maternity contract.

ironically untill this last pregnancy....i had no problems....at goal and happy with my band and xrays and endo to prove it 1 month prior to conception

I was told that it varies from state to state and then based on how policy was written.

My dr here is making one last appeal...... but i am not holding out hope.

Edited June 14, 2009 by burnsun

[MacMadame 81]

I think it does vary from state to state but it also depends on how the policy is written and which company it is.

When I was going through this, I found that my insurance company was adamant that they would not pay to remove a band, if it slipped or eroded. But when I asked about the sleeve, they implied complications would be covered. They said a leak would be treated like an accident.

Also, most of the complications you can have from WLS are things that can happen to anyone, even if they didn't have surgery, so it's harder to deny them. For example, you can get a kidney stone or a blood clot at any time. Sure, surgery ups your risk, but they can't absolutely prove that surgery caused these things.

The leak is the only thing I can think of that is directly related to surgery and, even then, some insurance companies will cover it anyway. My surgeon says about 90% of his self-pays who get complications get them covered by insurance.

I still took out a home equity loan just in case prior to my surgery. (Well, I tried to anyway.... long story.) I figured that I might end up out of pocket by as much as 40K if I had a leak so I wanted to be prepared.

[Elisabethsew 50]

In N.Y. leaks are covered by insurance by nearly all carriers (got that info. from the billing dept. of the health care system I work for).

[Bandedbut 25]

I just posted a similar question in the insurance forum. I was a self pay banster, but was told insurance WOULD pay for complications. It hasn't covered an unfills due to dehydration though. There is no way I could pay for removal/revision right now, but can't live like this either.

[Oregondaisy 2,021]

Thank goodness Dr. Aceves has never had a leak. I know complications are very expensive, but I trusted him so much, I wasn't worried about complications.

[Daisalana 33]

I just posted a similar question in the insurance forum. I was a self pay banster, but was told insurance WOULD pay for complications. It hasn't covered an unfills due to dehydration though. There is no way I could pay for removal/revision right now, but can't live like this either.

My insurance will not pay for ANY complications. The policy says they do not pay for anything related to obesity treatment, including complications.

I have had to have a surgery to fix, I had to have testing, etc. done; and my insurance is adamant, they will not pay. Even if the band was eroding, I would have to come up with the money myself.

Definitely call your insurance to confirm with them, as I know mine did not budge.

[TexasT 99]

If you have insurance you must check your policy. Mine will not pay for anything related to obesity help - no matter what. So I would to have to pay for anything to do with complications. My revision from band to sleeve surgery is scheduled for 10/30, and now I'm not even sure I'm going to go through with it. I'm self-pay, but am also have gallbladder removal, which is covered by insurance. My doc is charging me $5000 for the sleeve portion of the surgery. I'm just afraid of having to pay for complications if something were to happen.

[kaykay 1]

Some surgeons offer some kind of insurance called BLIS. I don't know much about it but it apparently pays for complications if there are any. Apparently, the surgeon has to be part of this group that participates in BLIS insurance.

It is a risk to consider when you are self-pay, (my husband was self-pay too) but at the end of the day, I think a lot of people end up feeling like it's worth the risk to go ahead and proceed with it.

Edited September 11, 2009 by kaykay

[Chancie 65]

I'm a self pay- and my surgen has the BLISS insurance. I paid my fee in full the week prior to surgery and have not had to pay anything since-

All my visits are covered, my blood work etc.

I had to spend 5 days in the hospital instead of 3- all covered.

I believe the BLISS insurance covers everything for a year... Leaks included.

As kayKay stated, your surgen has to be part of this plan.

I'm not sure how everyone else's surgens are, but with mine- you are a "lifetime" member- all nutrisionist-phscoligist run support groups- and exercise consultants are free.

[MacMadame 81]

BLIS is great but so few surgeons are in the program. Bah!

My surgeon told me that he would not charge me extra for his work in helping with any complications, btw. (I forgot to mention that before.) But that the hospital absolutely would charge me, if I was in there for more days than overnight for the surgery.

[ryansgirl 1]

My insurance payed for everthing when i got home and had complications. if they cover some kind of weightloss then most likely they will cover the bill.

nikki

[lowkee00 1]

Thank goodness Dr. Aceves has never had a leak. I know complications are very expensive, but I trusted him so much, I wasn't worried about complications.

If you are referring to the leak test they give you a couple days out, then yes maybe Dr. Aceves never had a leak in that time frame. But I can tell you that he HAS had patients who have had leaks later down the road. I am in the over 2% that have complications and mine were the worst case imaginable outside of dying.

I am going to post my whole story in the next week or so, but to sum it up quickly, I had the sleeve in Mexico, had a leak 3 months later, spent 5 months in the hospital with sepsis, 2 in a coma. My wife was told first night I would most likely die. Insurance DENIED all bills, 1.5 million to date. If I would have had the surgery in the US and had problems, they carry a separate insurance policy to cover problems after the fact. Keep this in mind as you pay the less expensive surgeries out of the country. As of today, I am bankrupt, lost my home and was denied even physical therapy to help me walk again after serious dropfoot and muscle atrophy. Oh yeah, and I developed a huge abdominal hernia a week after I got home. Surgery in 1 year to fix that. Blue Cross/Blue Shield.