CRL (Central Res Life)????

January 31, 2005

I am in the beginning stages of researching/comtemplating lap-band surgery. My insurance co. is CRL (Central Reserve Life). There is a loosely worded exclusion for obesity treatment in my policy, and I have e-mailed the ins. co. regarding coverage, and they e-mailed me back a NO. Anyone have this ins.? If so, anything you can tell me is greatly appreciated!

Elizabeth D.

porclndoll · February 1, 2005

Elizabeth...I do not have your insurance, but if ya let me know what your policy says I may be able to help you form a stratagy around it...........maybe........I use to work for Empire BlueCross BlueShield and learned a lot working there. Does it say if medically necessary? Empire typically covers the surgery but it needs to be preautherized...which means documentation sent in by your provider and you need to meet a certain list of qualifications. I don't know if your policy is set up the same way. Maybe it is saying no on just weight loss programs such as Weight Watchers or Jenny Craig....Lemme know if ya need help........

the best me · February 1, 2005

Porclndoll,

I have an insurance question you may be able to help with, given your experience in the field.

Heres' me...right now I have group coverage through my husband's company with BC/BS in NC which does NOT cover the Band. It is an exclusion under weight loss surgery. Gastric Bypass is not an option for me. I have been doing some math and coming up with a price tag of almost 20,000 for self-pay with my nearby weight loss doctor, who will not do fills for Mexican bands.

So, at that price, I decide to have the surgery in Mexico and I need to count on him (in MX) to do my fills and aftercare and the price tag works out okay. That assumes NO complications. Say everything goes fine, I lose all kinds of weight, I am healthy and happy, me and my band look like Belinda in a bikini in the Before and After photos (way to go Belinda!) Say we want to drop the group coverage and go with a less expensive personal plan with no maternity benefits (tubes tied) I have to tell them I have a Band and where I got it, or I'm lying and they can really get me later if something happens. Can they, would they, could they, deny me coverage with a Mexican Band? No complications, only better health, a healthy weight and no more co-morbidities (such as joint pain, arthritis, rashes, fatigue, high blood pressure, high cholesterol, the beginnings of diabetes, etc. None of that) What are the chances of being denied future coverage with a Mexican Band?

Elizabeth, I think I have officially hijacked your thread. Sorry! I guess any insurance info is helpful to everyone. Anyone else? Jump on in here! thanks!!!

porclndoll · February 1, 2005

Hi Kathy....I don't know everything, but what I would assume would happen, your new insurance may consider your band a pre exisisting condition. They may hold claims on fills (if they cover fills at all) until the pre exisisting condition time frame expires. Some policies say they wont pay on pre exisisting conditions for 60 days from your policies effective date. However on the policies that I have worked on for BCBS they had an exclusion on the pre exisisting clauses saying if you have had insurance within the last 60 days from the day of your effective date...then the preexisisting clause is void....you don't have to wait on your claims to be paid. SOO basically the preex clause is only vaild if you have had no insurance prior to your new policy...which you have had insurance. I don't think they would deny you coverage especially under a group policy thru your employer just for the band. One tricky thing about group insurances is that the employer helps the policys development...if they say cover band aids, then the insurance company covers band aids....if the company says covers lolli pops, then the insurnace company covers lolli pops. I worked on a group policy for Morgan Stanly in New York City...a huge investment/stock broker and they had excellent coverage.....I also worked on ummmmm another HUGE company in NYC.....I forget the name now, but if ONE person complained about coverage, the company would approve the charges!!! It was wild. It was like why even have a policy if everything was getting pushed through....but I digress.....I hope this has helped your question in some way

Good Night !

the best me · February 1, 2005

Thank you so much! I understand everything you have said, especially about the pre-existing clause. All that makes sense...but one more question... What if I am moving from a group plan (where they MUST cover me simply because I'm eligible for the plan because of employment-or that of my husband) to a plan where I just buy insurance as an individual and pay the premiums. I tried to do this several years ago after my daughter was born and I quit work. Cobra was ending and I applied for coverage for the family, then was denied coverage for me, but they said they would insure my husband and daughter. I was too high risk (due to weight, maternity benefits, previous C-sect, etc) they figured it would be too expensive to cover me, no matter what my premiums were. So they simply said "No, not you, but everyone else is okay" which made me feel like a huge loser, big, fat, uninsurable, not worth our effot loser. Needless to say, I did not accept their offer to cover DH and kid without covering me also. Which is why we went for the pricey Group plan through my hubby's company, since they can't tell me no. It's a pitiful situation to put your family in...to be too fat for insurance...it's costing us a pretty penny, too. I feel terrible. My hope with the band would be to lose the weight, no longer be a burden in so many ways, and finally be able to get more affordable health care for our family, without me having to go back to work just to get me insured so my family can save that money. But...I digress as well...we are just two peas in a pod going on and on...I like your lengthy posts.

So, to summarize the actual question...what is the likelhood of say, BC/BS denying individual coverage for me and my family based on the fact that I have a Mexican placed band?

Thanks for your input. I really appreciate it.

By the way, any news Elizabeth?

porclndoll · February 2, 2005

Kathy,

Im sorry, I skipped right over your question basically about self pay insurance. My experience is with group plans.....not self pay.. I would imagin with a self pay they can deny you coverage for any reason, but in this day and age, I don't see how they could. If memory serves me correctly, there are federal laws that protect people with certain illnesses...such as cancer, and obesity. Maternity and breast health are protected by certain laws too. Just gotta ask up front, but you all ready knew that... Sorry I couldn't give you more specific info....good luck to you!! I am not banded YET either. I have an initial consult with the surgeon and dietician on 2/10. I am anxious to see how long the insurance company takes to approve/deny.

Talk to you later

the best me · February 2, 2005

Keep us posted on your consult...it's good we have been doing all of this leg work up front. DeLarla has certainly given me much to consider. I may finally end up in MX, but if I do, I know better about the risks and what to look for...I have an appointment with my PCP in a few weeks, if she is on board with the Lap Band, I will feel lots better about things. I want someone local to call who knows what's going on! And as few surprises as possible. I will also call my insurance agent, maybe she knows someone who could advise about whether or not they would deny me future coverage. I'll let you know what I find out and post it here for others. I was talking with DH last night, and the truth of the matter is, if I do get the surgery, I will have to go back to work in the fall anyway to pay for it! That is a group plan so I really have no worries for at least a few years. I need a new/used van too. I really do need to go back to work. DH is a trooper...he ain't skeeerd of the debt and he likes the experience of the MX dr's over the US, and as long as I follow the advice and have aftercare taken care of, he is very supportive. Ideally, my insurance would cover it. You are very fortunate to have the coverage, even if you have to wait. It may be a few more weeks than you'd like, but you will get there. Good luck to you as well. Thank you for all your help! See you on the boards!