Unethical bandsters?

[txbldhnds 0]

My insurance would not pay. I went through all the appeals and was rejected repeatedly. It took me 3 years to come up with the money.

While I was still waiting & saving, my sister "fudged" and her insurance paid for every penny of her surgery.

It pisses me off!

Not that her insurance paid. But that she cheated and it paid.

That ain't right.

[lotsofkids 0]

hopefully you will lose more than your sister as you will value your band and waited so long to get it.

It must be very hard for all of you self payers to read this thread....as you suffered with your wt and with your wallets!

warm wishes to you and best of success in your journey.

smiles...diane : )

[Wheetsin 714]

Let me throw in a few questions, and feel free to ignore them as much as you want. I'll say up front that these questions do not necessarily reflect my personal opinions, but I want to ask them because I think they might make for interesting conversation.

1. Should people on publicly funded insurance, e.g. "my tax dollars pay for their medical care", have WLS covered? I think the self-pays' responses to this will be particularly interesting.

2. Should insurance companies be able to impose a time limit before something with debatable medical necessity is approved? I see the "it saves them money in the long run" argument -- but the numbers don't back that up, at all, and that's why there are more and more denials coming down every day. The average person doesn't stay with their insurance company long enough for the business to see the fiscal benefits. For example - I started with my new company in June of last year. I had surgery March of this year. I had 3 office visits not related to surgery, but surgery related billings in excess of $35,000. (Meaning, if I hadn't had surgery, I would have cost my insurance company a couple hundred dollars). I can change policies in November when we have open enrollment. If I change carriers, I just cost my insurance company a LOT of money, because they'll never get enough premium from me or my employer to come remotely close to what they paid out for my surgery. So back to the original question -- should insurance companies be able to impose a waiting period before they'll approve surgeries of questionable necessity, to ensure they're not out a ton of money on an elective procedure? (I think the necessity of all WLS is debatable, when compared to things like trauma surgery)

3. On the flip side of that, if someone has WLS, and does not lose enough to get off their medications, or stop their pain, or whatever - AND it can be attributed to much of their own doing - poor eating habits, refusal to exercise, etc. - should they have to pay back any money to their insurance? E.g. the situation is such that - the insurance company did their part, you did not do yours and are costing them as much if not more as before... should they be entitled to any kind of "refund" from you? (Note this is not band-specific...)

[3loves 0]

Just the word "insurance" irritates me. I feel regardless if you are going for WLS or just trying to get a regular claim filed, you will have an occasional fight on your hands to get the benefits you have paid and continue to pay for. At least this has been my experience since I was old enough to start paying my own insurance. I have to carefully watch and monitor every claim that comes through to make sure it is paid properly.

I have a claim for my son from last year that is still unpaid b/c NGS (my ins company at the time) thinks it may have been a car accident. They sent a form requesting a life history (BTW, I'm not able to go online and provide this info, only my snail mail) to verify the claim. He was in an accident at school and needed stitches which is clearly documented in ALL paperwork. They paid part of the claim, but this part they just want to put off in an effort to see if I'll take the time to file the ADDITIONAL paperwork to get this claim paid. I don't know what this is actually called, but there are a certain number of claims everyday that go through a similar process to provide more cash flow for the insurance company. They can delay paying and sometimes get out of paying what they should have paid in the first place b/c some people won't take the time for follow-up. WHEW....glad I got that out. :tired

Now, on to another point regarding insurance......this is copied and pasted from a thread I posted when I was trying to get approval. It seems I was nearly denied for being completely honest. I think we are living in a day and time where people are forced to respond in a negative way just to keep up with some of the antics being performed my insurance companies today.

~ The medical records I submitted from my Optifast last year showed non-compliance. Yes, they did indeed state that on different occasions b/c I was always completely honest if I had something other than the shakes/bars. On these occasions, I was light-headed, shaky, and thought I may even pass out so I would have A cracker or A slice of bread with Peanut Butter. Another time, I ate a piece of cake at my birthday party. Another time I ate 6, yes I counted and put that on my sheet, 6 Frito's just b/c I wanted them.

I told Patty that I do not understand how they can consider this a failure for me since I did lose weight....I lost 32 lbs over 3 mos. She then said, well this surgery is for people that can't lose weight. WHAT?? I thought I was going to blow!! I stayed calm and told her that if I could keep the weight off, why would I be asking for WLS? It seems I am in a no win situation with them.

I then went on to tell her that I have specific records from my family doctor (she confirmed they had them) from 1992 showing different weight loss attempts & I always put the weight back on and more. She said the medical records had to be recent. My records run from 1992 - Nov 2004. We moved to IN in 2004 so I had a new doc. I told Patty that I am very surprised that I need to address such an issue as the non-compliance and that I would go to my grave saying that I did not fail that program. She did try to be encouraging and said that they haven't said no yet, but they would resubmit if I got the new evaluations.

I feel that once I get the evaluations corrected/complete with my surgeons office, they are going to deny me based on my Optifast program and non-compliance. My husband told me I was too honest. Now I'm feeling it doesn't really pay to be honest if this is the game I have to play. I felt I was only hurting myself if I wasn't forthcoming with every little thing I put in my mouth while on the Optifast program. I mean, I told everything every time. What is wrong with me?

I ended up getting an advocate involved from my DH's company since they were self-funded. She even had to plead my case and told them she felt I was qualified. I plainly told her I felt this was a case of insurance trying everything they could to deny what I was entitled to. After a couple weeks, I was finally approved.

Why should it take so much work and effort on our part to get the benefits that are listed in our policy? I am thankful to have insurance, but feel I also have to watch EVERYTHING very carefully to make sure I get what I pay for. Insurance is need of a MAJOR overhaul. Personally, I don't think universal coverage is the answer, but changes do need to be made.

Insurance is a game and sometimes you have to play by their rules or you won't get the benefits you deserve. That is how I feel even though I have always been 100% completely honest about everything I've submitted. It's just that I've been Enlightened by my lapband experience & that being honest with insurance companies can have consequences.

Boy, am I windy today or what.....sorry for the long post. :faint:

[TommyO 5]

<TABLE id=HB_Mail_Container height="100%" cellSpacing=0 cellPadding=0 width="100%" border=0 UNSELECTABLE="on"><TBODY><TR height="100%" UNSELECTABLE="on" width="100%"><TD id=HB_Focus_Element vAlign=top width="100%" background="" height=250 UNSELECTABLE="off">Wheetsin, I was self pay and I have no problem if my tax dollars paid for someone else. I have been fortunate and I can afford to pay my own way, I have no problem with some one who is less fortunate getting their surgery paid for.

When I decided to have my lap band surgery it was because I was afraid for my life. I can't imagine what it would have felt like to be in that position and not be able to afford the surgery. I do not care that people put a little sand in their pocket or that some people may do this for superficial reasons. Most people on this board and by most I would say 100% chose this surgery because of a desire to live. Not because they wanted to shed a few pounds off the old hips.

To any one who suggest that wearing heavy clothes or putting a few heavy objects in the pockets constitutes an imoral act I say get over it.

Finally if I have to read another post about the fat people who eat and eat and who are not trying to do anything abouit their weight problem I am going to start to get upset. In my life I have never met a fat person who didn't have losing weight as their number 1 priority. When we see overweight people out in public and they appear to not care about their obesity we more than any other people should understand their situation and forgive them. We have all at one time or another said F--K It and appeared not to care.

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[nursekathy2u 0]

As far as MEDICARE covering WLS I dont have a problem with that. Most people have worked at some time in their life and paid taxes of their own. I guess the same would go for MEDICAID.. We say it is "our tax money" paying for the surgery but most people have paid some taxes of their own. Besides.. "our tax money" can either pay for WLS or meds and bills for caridac disease, diabetes, athrititis, etc. I have been a nurse for 22 years and have been working and paying taxes since I was 14 yrs old. Two years ago I injured my back.. REALLY BAD... It was workmans comp but since there was no slipped disc or anything that could be fixed surgically they wanted to settle with me.. I said no to a settlement because I had hopes of eventually healing and returning to work. If I had settled you get some sort of rating that follows you from job to job and would affect my ability to get a good job in the future. So they just quit paying.. sent me a letter saying I was likely to never heal since I was so fat and they couldnt just keep paying for me to have steriod injections in my back. I was furious.. I only took 4 days off of work with the injury. Did all of my physical therapy and pain injections on my own time and refused to take a big cash settlement from them. I only wanted them to pay for the pain injections. My injury happened in surgery in front of the whole surgical team and the surgeon.. I had a ton of witnesses.. It didnt happen because I was fat!!! Can you believe I still work for the same company??? Anyway... long story to say that at that time in my life I was really scared I would become disabled. If I had become disabled and sought money from the federal government for my care.. should I have not had the opportunity to have WLS paid for by "your tax money"?? I paid into that Tax money for 25 years too. Or what if I decide to have a bypass when I am 65 and on medicare?? Why shouldnt they pay?? THey have taken enough of my money throughout the years.

Now.. the people who make welfare and medicaid there way of life because they are lazy should be taken out back and shot. There is NO excuse for milking the government when your just plain lazy. That is another story. (This comment does not apply to those folks who have fallen on hard times and need assistance.)

Now as far as the question about insurance compaines I have mixed feelings.. the same question could apply to the person with emphysema on oxygen and inhalers who continues to smoke and eventually develops lung cancer.. Or the alcoholic whose health is effected by the chronic alcoholism but they continue to drink..

I have a friend who worked for a well known insurance company who told me that all claims received on the third friday of the month were trashed. That meant the claims would have to be resubmitted and it prolonged payment. Insurance companies suck but then again I dont know what I would do without my health insurance coverage.

Kathy

[katt 0]

I am so blessed that I have a wonderful job that I love which pays me enough to enjoy a lifestyle that I never imagined I would be able to afford. That being said, I am self pay because WLS is excluded by my insurance company. I, of course, wish my insurance company would pay but I am also thankful that I can afford to pay for it myself. I think something is wrong with our entire insurance system. I do support Universal coverage. There are millions of working poor who have no coverage at all. It places a burden on the whole system. It overcrowds our emergency departments to such a level that lives are lost daily because hospitals can't handle the loads. We, as a nation, have a responsibility to take care of the least of our citizens. Katt

[Wheetsin 714]

Finally if I have to read another post about the fat people who eat and eat and who are not trying to do anything abouit their weight problem I am going to start to get upset. In my life I have never met a fat person who didn't have losing weight as their number 1 priority.

I don't think it's anything to get upset about. Most fat people do have losing weight on their top 5 list. But there's also the belief (I personally do believe this) that people do everything they do because they get something out of it. That includes being obese (you can see previous posts for examples or reasons). I believe that an awful lot of obese people do not lose the weight because, deep down there somehwere, what they get out of being fat at any particular moment sort of outweighs what they perceive getting out of being thin. That can be on conscious and subconscious levels. And it can change throughout time, depending on what the perceived gain or loss would be, as compared against what you need in your life at that particular time. It's also a reason why I personally would advocate for mandatory counseling during weightloss efforts. I also believe fat = depression. You can't be significantly obese and not have experienced at least situational depression, workplace depression, etc. at some point. And when you're in a state of depression, it's easy to not care and go "frumpy".

Again - please don't see this as something to get upset over. Everyone has different opinions and perspectives. If there were no differences in beliefs, the world would be a pretty static place.

[3loves 0]

I have a friend who worked for a well known insurance company who told me that all claims received on the third friday of the month were trashed. That meant the claims would have to be resubmitted and it prolonged payment. Insurance companies suck but then again I dont know what I would do without my health insurance coverage.

Kathy

Now I know it's true!! :faint: I have a friend that told me a similar thing and I didn't want to believe, but when I would have to resubmit or call several times b/c the insurance company said they didn't have the info, it did raise my curiosity. Like I said in an earlier post, I feel like I have to fight to get my honest claims paid and paid in a timely manner in which does not affect my credit rating. This attitude that so many of us have experienced, shows that consumers are forced into a reactive mode instead of being proactive in most cases. It's no wonder some people feel it necessary to put quarters or sand in their pockets. They are just playing the game that insurance companies create. I'm not condoning these actions and hope that I'm never in a position to choose. What if one of my children needed a life-saving procedure? You can bet the house, barn, AND the land that insurance would have everything they needed to approve any such issue regarding my family. I would walk on Water with the help of the Lord if I had to.

Bottom line.....insurance companies hold too much power to determine our health care. The sad truth is that some of these people that make final decisions are not properly trained in EVERY field that they are covering. This is wrong and should be fixed. Anyone have any ideas?

[NewSho 20]

... But there's also the belief (I personally do believe this) that people do everything they do because they get something out of it. That includes being obese (you can see previous posts for examples or reasons). I believe that an awful lot of obese people do not lose the weight because, deep down there somehwere [sic], what they get out of being fat at any particular moment sort of outweighs what they perceive getting out of being thin.

OMG, I could NOT disagree with this more.

This is one small step away from "Fatty, you're just fat because you're lazy or because you want to be fat."

The mere thought that I was fat because I wanted to be is simply preposterous.

I've been banded 5 freaking years - and didn't look it until a short while ago. But it would enrage me to have someone possibly think "deep down there somehwere, what they get out of being fat at any particular moment sort of outweighs what they perceive getting out of being thin. "

Nothing could be further from the truth.

I knew I was fat, and would be fat for life. I took VERY proactive steps to address this problem. I invested my time, my money, my career, and my previously-unscarred body to try to fight the battle of the bulge.

I got banded, had a huge setback and stayed obese for years.

I bought a tool and it didn't work as it was supposed to do.

This was NOT what I wanted!

It did not serve a purpose, fulfill some fantasy, or make me feel complete.

Being obese has been one of the most devastating parts of my life.

And it was gut-wrenchingly horrible to have people look at me every day wondering "Why did she even bother to have that operation? She's still fat."

That can be on conscious and subconscious levels. And it can change throughout time, depending on what the perceived gain or loss would be, as compared against what you need in your life at that particular time.

Sorry, I think this is B.S. and over-reaching plus over-generalizing.

It's also a reason why I personally would advocate for mandatory counseling during weightloss efforts. I also believe fat = depression.

Oh, yeah? Guess what. I wasn't fat because I was depressed (although this is a very common correlation) but I was depressed about being fat. It wasn't consciously planned to stay fat or subconsciously being happy that I was fat.

It was a tragedy.

You can't be significantly obese and not have experienced at least situational depression, workplace depression, etc. at some point. And when you're in a state of depression, it's easy to not care and go "frumpy".

Never.

If I couldn't find or fit stylish, fashionable clothes it was because they didn't make them in my size (and many fashion designers & trendy stores are guilty of this ) but I never allowed myself to be frumpy. It may be easy for some, but just because I was obese didn't mean I didn't ever give 110% to be as polished as I could. I live for fashion, live for clothes, live for shoes, live to shop - so to be obese literally was killing me inside.

Again - please don't see this as something to get upset over.

Too late.

Everyone has different opinions and perspectives.

Yes, we sure do.

And to these comments, they may be your situation, they may be the situation of those you know, but please realize they are not indicative of what all obese people feel.

[TommyO 5]

<TABLE id=HB_Mail_Container height="100%" cellSpacing=0 cellPadding=0 width="100%" border=0 UNSELECTABLE="on"><TBODY><TR height="100%" UNSELECTABLE="on" width="100%"><TD id=HB_Focus_Element vAlign=top width="100%" background="" height=250 UNSELECTABLE="off">Wheetsin, there are multiple reasons that people are fat and I maintain that none of them are because of a want to be fat. Your suggestion that

"people do everything they do because they get something out of it. That includes being obese (you can see previous posts for examples or reasons). "

Is incorrect.

People who are protecting themselves from the pain of sexual abuse or rape or any terrible act that has been perpetrated against them are not fat because they want to be fat they are fat because they don't want to be sexually abused. There is a big difference between a desire to be fat and a need to be safe.

Your short sighted argument is one that allows us to ridicule the fat person rather than having compassion for their pain. It gives people a free pass treat an obese person with disdain because it blames them for not only being fat it also ignores the rape.

There have been multiple studies done that prove that obesity is rooted in physiology rather than psychology. If you also have had some severe psychological trauma in your life it is likely to be compounded by your increased capacity for becoming obese.

I am disappointed when a normal weight person negatively judges an obese person but I understand that there prejudice is based in ignorance. For an obese person to negatively judge another obese person, to me, is unconscionable

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[JMO 0]

NOT UPSET!!

Wheetsin,

I do disagree with the mentality that I am fat because I want to be. I am fat because I have an addiction. Just as a drug addicted person, and some one who depends on a beer. I depend on food. My best friend in the world is food. When I am happy ,I eat. When I am sad, I eat. When I am mad, I eat. It is an addiction that I have tried hundreds of time to break..

Everyone,

I also do not offer any appoligies for gaining weight to get the band. I have been a hard working person for 20 years. I have paid my ins. out of my check for years..... With the amount I have paid them I could have paid for my surgery time and time again. If the ins. companies can trash all claims on the third friday of the month, (they are not being honest) why should I feel bad about gaining the weight back, that I had just lost on my own, To get something I needed to save my life. I am not one who put on a few lbs. after my babies. I have struggled my entire life being fat. I think everyone on this board knows what it is like to hate being fat. And scared you are going to NEVER lose weight. My doctor wanted me to have the surgery, I wanted to have the surgery, Why should someone who has never known me, and seen my struggles, decide my fate ,with a difference of a few lbs.

I think this also needs to be thought about. When RNY first came out. They had many stipulations on the surgery. Most people were self pay because the ins companies would not cover it. NOW all ins. companies cover it. Your employee may write it out of the policy, but all ins. carriers now cover RNY. I think in the next 5 years all ins. companies will cover the lap band, its just something they have to warm up to.

For anyone who judges me, Please, I sleep fine with my decision. Don't throw stones, if you live in a glass house. (i think it goes something like that) lol the point I am trying to make is that, unless you are perfect and have NEVER done anything wrong, you can't judge me.

[Wheetsin 714]

OMG, I could NOT disagree with this more

Great!! I'm glad you disagree with me. It's only when divergent opinions come together that new discoveries can be made. We wouldn't have as many views/responses to this thread if all that ensued was a series of "I agree"s, so something is happening: thought, positions, etc. -- and that's fantastic!

And to these comments, they may be your situation, they may be the situation of those you know, but please realize they are not indicative of what all obese people feel.

NewSho, everything I stated was a matter of my personal beliefs/opinions. I don't have time to separate everything into individual statements, so in an overarching way, I never said my thoughts were "right" (that would require a single finite reality, which by definition is impossible), nor did I ever insinuate it to be indicative of what people feel. I never made generalizations, etiher, because it's what I think, not what is. I'm not at all offended that you believe differently from me, so truly - don't be upset because I have different beliefs than you.

Tommy...JenMomto3, etc...

People who are protecting themselves from the pain of sexual abuse or rape or any terrible act that has been perpetrated against them are not fat because they want to be fat they are fat because they don't want to be sexually abused. There is a big difference between a desire to be fat and a need to be safe.

...please note that I did not say what you're claiming I did. I did not say people want to be fat, I said they get something out of being fat. There's a huge world of difference there.

For example, I don't think many people want to be in an absusive relationship, but I know for a fact that many people are. Perhaps just one of the many reasons why they might stay in a situation they don't want to be in is because they're getting attention, and when attention is what you need most (a.k.a. your perceived gain), then the negative attention of a punch in the face is better than no attention at all. (This goes beyond hypothetical - I've counseled an awful lot of women for whom this was the case - and my own mother lived it for nearly 3 years before she met my father). This predicament goes far toward to helping make sense out of the vicious cycles & self-fulfilling prophecies we see every day.

A feeling of safety can be exactly what a rape victim gets out of their obesity. For some it may be control. For some it may be companionship. For some it may be a barrier of protection. And on, and on.

So... quite contrary to the words that are being put in my mouth, I don't think people want to be fat. I know of very few people ever who have sat down and made a conscious decision to gain weight, or made it their New Year's resolution to gain fat (I personally only know 1 person who has ever done this).

Cheers! :confused:

[nolagirl2 0]

I agree with Wheetsin.

For my personal experience, I know that with each new WL attempt came a fear of failure, and a fear of success. I have been overweight/obese my whole life, so I don't even know what I look like under all this. That's pretty scary.

And what about between WL attempts? After failing, or after succeeding only to then regain. I always felt "Well, why do this hard thing that is just going to fail, when I can do this which is easy."

Everyone has different feelings, beliefs, and situations. It might not be true for you, but its definitely true for some.

[TommyO 5]

<TABLE id=HB_Mail_Container height="100%" cellSpacing=0 cellPadding=0 width="100%" border=0 UNSELECTABLE="on"><TBODY><TR height="100%" UNSELECTABLE="on" width="100%"><TD id=HB_Focus_Element vAlign=top width="100%" background="" height=250 UNSELECTABLE="off">Me thinks you are splitting hairs, when the debate focuses on the words and not the intent of the words the debate becomes silly. Want, need, desire, whatever term you use, as long as you use them it allows the blame to be placed on the victim. Every time someone rationalizes anothers problem by stating "they do it because they are getting something from it" you allow others to assign blame on the fat person.

I am not fat because of how it somehow protects me, I am not fat because of some benefit it provides. I am fat because of a lifetime of learned responses and a strong instinct to eat. In my case it is physical not mental, No one has worked harder than I to not be fat, although I am certain that many have worked as hard. I will continue to fight the good fight and I will continue to root for all those folks who are fighting their own good fight. I refuse to be minimalized by the legions of Doctor Phil fans who have decided that I am fat because I choose to be because I get something from it. I refuse to blame fat people for being fat and every time someone expounds the huey that fat people are fat because they need, choose, want, desire,get etc to be fat they give everyone a free pass to treat me with disrespect because it's my choice.

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