Med exclusion. Shouild I take their word for it?

webkat · May 7, 2007

I called my insurance, Healthnet, and they said it is a plan exclusion. They don't cover Lap Band at all. (Lap Band says they are a Lap Band friendly company) The guy even supposedly asked a suppervisor to make sure. Should I just take his word for it? What do I do next? Has anyone else had this problem? Should I change insurance?

~Kathy

faithmd · May 7, 2007

Just because the insurance company covers LapBand surgery, doens't mean YOUR plan includes it. your employer very likely chose an exclusion for WLS because it is more expensive to them to cover it.

Did they look up your specific policy (get your name and birthdate or your policy # from you?) when they spoke to you? If so and they said it was an exclusion for your policy, then there isn't really a lot you can do.

A next place to check out is www.obesitylaw.com it's a link to a lwyer who works for people to get insurance to cover WLS. But if your policy excludes ALL WLS procedures (WLS=weight loss surgery), then there isn't anything you can do. But if they do cover bypass, but not the Band, then you may be able to get somewhere.

You may be needing to self-pay.

I wish you loads of luck!

rico · May 19, 2007

I got the same answer from aetna (excluded). I decided to call back more times to see if I got another answer and each time I did. Call them back and tell them that a surgeon told you to ask if the company you work for would pick up a "rider" for the surgery if it is medically ness. Good luck!!! If this doesn't work talk to either or both the employer or insurance and tell them your thinking of contacting your state insurance commisioner.

Alexandra · May 19, 2007

Yep, Kathy, your specific insurance policy can have all sorts of riders and exclusions if your employer is large enough to negotiate them with the carrier. Call your human resources department and make sure you have the documentation on your policy that lists all the exclusions. If you DON'T see bariatric surgery on that list, then you need to do further exploration. If you DO see it, then you might have a problem. It's very unlikely your employer would be able to modify the contract until the next anniversary date, even if they want to.