Self Pay--But Insured, What About Complications?

[MuzzyDN 1]

I am self pay and have surgery scheduled in November. I have insurance, but have to be bmi of 50 to be covered.

I am concerned about complications and those not being covered by insurance?

Has anyone had experience with this--I seem to be finding situations where they do cover complications that arise and others where they don't. I have Kaiser Permanente in Oregon.

I am wondering if it is better to be proactive and ask membership services if they would cover complications, or just keep my mouth shut and pursue that path if complications do occur?

I am confident in my surgeon and his practice, but there are always risks.

Thanks for any feedback!

[Foxbins 625]

I have Kaiser and was self-pay in Mexico because of a low BMI, too. I told my PCP I was having surgery in Mexico and although she tried to dissuade me a little bit, she also gave me the Kaiser post-op bariatric guidelines, ran labs for me, and hooked me up with their support groups. My understanding was that if I had complications, Kaiser would treat me.

[COsleeveDude 273]

Have you tried appealing? Kaiser in Colorado (and also in California, from what I've heard) only require 40 BMI.

[AngelEyesInNJ 186]

I am not familiar with your insurance but I know my UHC does not cover any type of WLS but if I have a complication and go to the ER I believe I recall someone telling me that would be covered. I am actually going to double check this but maybe that is something to check out if your plan would cover an ER visit and anything that goes along with it.

[lulugirl 20]

I went to Mexico & have had some issues. I have Blue Cross & am having no problems being seen by Arizona docs. I was hospitalized for 4 days & having more tests next week, it has all been covered.

They wouldn't cover my surgery because of my 37 BMI with no comorbidities.

[MuzzyDN 1]

Thanks for the responses! I am going to follow up with my PCP and see what he and/or membership services can tell me. That will make me feel better all around.

Thanks!

[Bufflehead 6,358]

It really depends on the policy. There should be a member handbook that explains what is covered and isn't. Typically complications from wls are only excluded if there is a blanket exclusion on wls. The clause will say specifically something like "weight loss or bariatric surgery and any complications arising therefrom." If weight loss surgery IS covered, but you just didn't meet all their requirements and went self-pay, usually complications ARE covered as well no matter how you got the surgery. But again, read your member handbook carefully. Another clause to watch out for is if complications from elective surgery are excluded. Self-pay weight loss surgery would be considered elective surgery so complications would not be covered. The lesson I have learned through my whole insurance ordeal: rely only on what is in your current member handbook. Don't rely on what the insurance people tell you over the phone -- they are quite capable of being wrong.

[Need-a-Sleeve 211]

Agree with Bufflehead. Customer service is not always right but even the benefit booklet can be an abbreviation of the plan as it may be supported by internal medical policy guidelines. Those aren't "secret", but you may ask for a copy.

I usually do these 3 things: get a copy of my current benefit booklet, go to the website & print out the providers (proof I checked on that day if they were in my network) and then make 2 calls to customer service. Take the person's name, date & time you called with the information they provided to you. IF it differs, call back & ask to speak to a supervisor or manager, tell them who you spoke with & ask why you got different information.

Remember, just because you have XYZ insurance, it doesn't mean all policies with that carrier are the same. There can be 100's of variations.

[Ms.AntiBand 2,984]

I agree with the above... It all depends on the policy. I too have BC but my policy strictly states that they will not pay for ANYTHING related to WLS. I had self pay MX surgery with over $75,000 complication cost and guess what? I have one savings account nearly drained. I fought tooth and nail for it to be covered under the medical necessity clause since my life did depend on it.. Hell, They didn't care. I was in ICU for days, unconscious for some of those, emergent surgery to remove the band so my BP would rise to join the living and .. Apparently, they think that's not medically necessary to save my life. Go figure, huh? And to think we pay $500.00+ a month plus what our employer contributes for insurance coverage. To say the least... I HATE INSURANCE COMPANIES. Grrrr...

[djssv0523 10]

Wow! Would you guys mind sharing what your compications were? Sorry in advance if they are posted elsewhere. I'm still learning how to navigate this site.

[iggychic 1,405]

I have BC as well and all complications have been covered so far (we expect the total bill to exceed $250,000). I wasn't covered for the surgery because of a low BMI and no comorbidities.

But we are self insured (we pay for all of our employees care and BC administers the policy). So in many ways we set what's covered. Our policy is quite generous for the most part. But I actually didn't expect them to pay so we're happy we didn't have to fight about it.

[Ms.AntiBand 2,984]

Yep, obviously, Ive got sucky insurance. No doubt in my mind. djssv0523.. Complications were due to the band and never ever for any thing due with the surgery or drs or locations where I received the bands. Bands slipped, eroded and ulcerated and I nearly bled out. For fear of regaining my weight I repeatedly refused to allowed the removal, but eventually on one of my ER visits I was unconscious for enough days that they were permitted to remove it without my consent. Prior to the surgery I woke up and they had to sedate me because I went ballistic on them. Thank God they I'd or I'd be a statistic or sure.

[djssv0523 10]

Oh my goodness how awful for you Kleigh830. Have you since had the sleeve surgery? Any problems with that?

[Ms.AntiBand 2,984]

Well.. I'm probably going to get the sleeve, but sadly I don't (yet) have my hubby's support. I guess it has to do with that whole dying thing and all. Ok.. Probably a little of the $ aspect of things too, but I've given up my Europe tour (by approx 10 mos) so I can obtain the sleeve surgery. Going to MX is not an issue for me. I have had such amazing experience down there that I would recommend it whole heartedly to anyone. BUT .. Do your research and don't just go via price comparison. My biggest fear is if by chance I have complications again.. Well, not only would I see my Europe trip disappear .. I kind of like having a savings that stays intact for retirement.

Dang, being fat sucks

[djssv0523 10]

I hear ya on that! Being fat totally sucks. I'm amazed after all that you have went thru that your willing to try again. You must be one tuff woman! I sympathize with your husband it must be hard to watch somebody you love go thru so much pain. I sincerely hope the next time is a walk in the park.