Your insurance company is NOT the enemy.

[LipstickLady 25,682]

In the majority of cases this is true, but it wasn't for me. I know it may not apply to many people, but it applied to me so I thought I'd share. I have Aetna through my employer (small group <20) and when I contacted the insurance company and they said it was an exclusion I spoke with the person who handles benefits at my company. She made several calls and found out that Aetna doesn't offer the bariatric rider to be purchased by small groups in CT. So, it is possible that an employer doesn't have the option, but obviously still not a reason to fight with the insurance company over it.

Go big then! Fight with HR to choose another company.

[MichiganChic 3,262]

In mine and my husband's case, it was the way the policy covers WLS that was the problem. They have the usual requirements, like a certain BMI for a certain length of time, 6 months medically supervised weight loss, etc., but those weren't the issue. The problem we had was that after you had met all the requirements and been approved, you had to pay the first $5,000 out of pocket before the coverage would kick in, then once it did, it only paid up to a maximum of $13,000. So after we added it up, we would have been out of pocket approximately $18,000 for each of us, which was out of the question. And that was just for the surgeon and hospital, it didn't include the anesthesia or any pre-op testing.

That is also the policy they employer bought. I have a similar insurance now, and I have to pay the first $2600 out of pocket before they ever start to cover anything - and that's for any and all medical coverage they do provide. I don't even think they cover WLS at all. When I had my sleeve, I worked at a different place, and the policy covered almost everything. If I didn't already have surgery, I'd be flying to Mexico for one of those $3900 gastric sleeves Alex is advertising, for sure!

[JamieLogical 8,727]

That's definitely untrue in my case. The BCBS provider in my area, Excellus, does cover WLS but with ridiculous restrictions. They require a documented BMI of over 40 for 5 years with no comorbidities or over 35 with comorbidities. I lost 90 pounds "on my own" in 2010/2011, which put my BMI well below 40. I regained and re-lost and regained and re-lost my way back up over the subsequent 3 years, eventually ending up well over a 40 BMI again. However, since I just got back up over 40 in the past year, I would have had to wait another FOUR years to qualify for surgery. I felt like they were punishing me for at least TRYING to lose the weight on my own. Had I just stayed fat back in 2010, I'd have qualified for WLS this year!

Edit: Here's a link to the specific policy on the Surgical Management of Obesity. Item 1B states: "The condition of morbid obesity must be of at least 5 years duration."

https://www.excellusbcbs.com/wps/wcm/connect/7626cc31-589a-449c-8757-09ef8ac1a985/mp+surg_obes+tac+#2+13.pdf?MOD=AJPERES&CACHEID=7626cc31-589a-449c-8757-09ef8ac1a985

That's the package your employer chose.

That's the only BCBS provider in my area. I suppose they could have chosen one of the other insurers instead of BCBS, but I don't even know what else is available around here. BCBS is definitely the only big one. Excellus definitely doesn't offer any better WLS at least. That link on their website is for their general WLS policy, not specific to any plan.

[LipstickLady 25,682]

That's definitely untrue in my case. The BCBS provider in my area, Excellus, does cover WLS but with ridiculous restrictions. They require a documented BMI of over 40 for 5 years with no comorbidities or over 35 with comorbidities. I lost 90 pounds "on my own" in 2010/2011, which put my BMI well below 40. I regained and re-lost and regained and re-lost my way back up over the subsequent 3 years, eventually ending up well over a 40 BMI again. However, since I just got back up over 40 in the past year, I would have had to wait another FOUR years to qualify for surgery. I felt like they were punishing me for at least TRYING to lose the weight on my own. Had I just stayed fat back in 2010, I'd have qualified for WLS this year!

Edit: Here's a link to the specific policy on the Surgical Management of Obesity. Item 1B states: "The condition of morbid obesity must be of at least 5 years duration."

https://www.excellusbcbs.com/wps/wcm/connect/7626cc31-589a-449c-8757-09ef8ac1a985/mp+surg_obes+tac+#2+13.pdf?MOD=AJPERES&CACHEID=7626cc31-589a-449c-8757-09ef8ac1a985

That's the package your employer chose.

That's the only BCBS provider in my area. I suppose they could have chosen one of the other insurers instead of BCBS, but I don't even know what else is available around here. BCBS is definitely the only big one. Excellus definitely doesn't offer any better WLS at least. That link on their website is for their general WLS policy, not specific to any plan.

Your employer chose to go with Excellus, a low cost licensee of BCBS. They didn't have to do that. Your employer chooses how much coverage they want to provide you. In turn, you choose to go with that plan or go somewhere else.

[B-52 7,113]

You are right...To A Point.

My office does nothing but process claims to insurance companies for pre-determination, pre-approvals, and later reimbursement.

It's what we do...I attend clinics everyday, each day a different Hospital/Facility, meet with patients and their families for evaluations, then submit to their insurance co. to see if they will cover the cost of what was prescribed at the eval.

Bottom line, Insurance companies do not like to part with their money...they are, after all, there to make money.

Not all are bad, there are excellent ones...

But sometimes, the illogical hoops they make you jump through...throw common sense out the window...you're dealing with real idiots!

Sometimes I think it is a tactic, that if they make it difficult enough, you will give up and go away.

And the more the federal government gets involved, the worse it gets.....then Insurance Fraud becomes more prevalent...only adding to more regulations and hoops...