Insurance frustrations

[Michelle Keller 7]

Can anyone help me figure out what this means? They said that bariatrics are included with our new insurance but this makes no sense to me. I’ve called insurance and all they did was read it to me and can’t explain it any further. I have calls into places to meet with surgeons but don’t want to get my hopes up if this isn’t going to happen. Thanks in advance.

[ms.sss 15,714]

Wow, they probably could have put in a bit more effort to make that more clear.

Though at first read, I get the impression RnY for morbid obesity is NOT covered.

The first bullet seems to eliminate all procedures that aren't bypass or sleeve. The second bullet seems to eliminate bybass specifically (but not sleeve?).

Can you post the list of what IS covered? As in "all other provisions as described in your Benefits Provision", and you can do a process of elimination....

P.S. btw I find it weird that the call centre can't just tell you if bypass is covered or not!!!

[GradyCat 3,695]

This is just the Rider making a change about Gastric Bypass. Where is the original policy language that talks about bariatric surgery? There should be more information there to make this more clear. (I used to be an insurance adjuster).

[catwoman7 11,220]

that's a head scratcher - yes, it might help to see the original rider. The way this is worded, I'm not sure what they mean..

[Michelle Keller 7]

57 minutes ago, GradyCat said:

This is just the Rider making a change about Gastric Bypass. Where is the original policy language that talks about bariatric surgery? There should be more information there to make this more clear. (I used to be an insurance adjuster).

The old policy didn’t include bariatrics at all.

[Michelle Keller 7]

1 hour ago, ms.sss said:

Wow, they probably could have put in a bit more effort to make that more clear.

Though at first read, I get the impression RnY for morbid obesity is NOT covered.

The first bullet seems to eliminate all procedures that aren't bypass or sleeve. The second bullet seems to eliminate bybass specifically (but not sleeve?).

Can you post the list of what IS covered? As in "all other provisions as described in your Benefits Provision", and you can do a process of elimination....

P.S. btw I find it weird that the call centre can't just tell you if bypass is covered or not!!!

I can’t find anywhere that lists what is covered and when I called the insurance they couldn’t tell me either, they just kept rereading the passage above.

[GreenTealael 25,430]

2 hours ago, Michelle Keller said:

Can anyone help me figure out what this means? They said that bariatrics are included with our new insurance but this makes no sense to me. I’ve called insurance and all they did was read it to me and can’t explain it any further. I have calls into places to meet with surgeons but don’t want to get my hopes up if this isn’t going to happen. Thanks in advance.

I hate insurance companies. Yours seem to want you to become Sherlock Holmes, a Bariatric surgeon, a contract Lawyer and then draw venn diagrams to figure this out.

It appears that this means that only Roux en Y gastric bypass with a roux limb longer than 100 cm is allowed under your benefits plans IF you fall into the category of morbid obesity.

It outright excludes the antiquated vertical banded gastroplasty (stomach stapling) and short limb Roux en Y by name.

You will have to look at the materials it says to refer to and find examples or call and ask for clarification on accepted procedures, but get it in writing.

It seems that no gastric restrictive procedures are covered unless they are also malabsorptive.

So your choice would have to be a Roux en Y gastric bypass with a roux limb longer than 100 cm and your BMI classifies you as morbidly obese in order for it to be covered.

You will have to pay for every other procedure (Vertical sleeve gastrectomy, Lapband, ESG, *maybe* mini RNY, and *maybe* DS/SIPS but the language is not clear on the last 2)

Below is a link to various types of Bariatric surgeries perfomed. Hope this helps ♥️

https://asmbs.org/patients/bariatric-surgery-procedures

Edited January 4, 2021 by GreenTealael

[Walter Lindstrom 42]

I'm sorry you're going through this. I can certainly help interpret the language (being an attorney and patient advocate who has handled over 10,000 bariatric surgery appeals over the last 25 years or so). Sorry to say I am pretty sure this Rider is an attempt to exclude all bariatric surgery that may have previously been covered. If you'd like to contact our office for an analysis I'd love to sift through what you're dealing with so you know your coverage from the outset. As mentioned by other folks responding to your question, I would want to see the existing coverage booklet (as a PDF) that this rider is attached to so we can piece together for you what's going on. You are correct in being cautious about moving forward and our office is here to help. Call us at 1-877-992-7732 and we can discuss this in detail - - - it's going to be a complicated puzzle to put together, but nothing we haven't been doing for a couple of decades!