Approved,but Only At 75%

[JohnC 31]

Yeah, I've been approved by my insurance co. after only 1 week:thumbup:. But the only down side is their only going to be paying 75% :banghead:. This includes all related cost but the surgery alone is $20,000 leaving my co-pay $5,000 not counting the pre-op test & fills. I'm happy to be approved so quickly but the hospital has already said they want the co-pay before they'll do the surgery. I can probably get it from my 401k plan but I 'd have to pay a pretty big penalty. Just wondering if anyone else has had their insc. only pay part of the cost. . JohnC

[MacMadame 81]

What kind of yearly limit to do you have on what you can pay out of pocket? It might be lower than $5000. (Mine is $3000, for example.) Plus any co-pays you have already paid this year will come out of that and make it even lower.

[jtorie 0]

I am sorry your insurance is not being very helpful! I've been told by many medical reps that my insurance is great! I think after hearing the stories on here I'd have to agree. My out of pocket expense is 10% up to a maximum of $1000. I have already met and surpased that, so other than the pre surgery testing. I will have minimal fees for the surgery. I was getting prescriptions at our local pharmacy and about 4 other people from my lap band info class were there, and had the same scripts. my co pay was the cheapest by far at $24.00. Everyone elses were about $60 - $200. Even the pharmacist said something.

I don't take that for granted in the least, money is tight!

I don't know much about insurance, but is there anyway to appeal that?

[JohnC 31]

Macmadam, That's a good thought, I'll

check that out.

jtorie, I understand I can protest it after the surgery.

Thanks for your suggestions guys.

[Ellisa 6]

JohnC,

Not to be a "downer" here, but IF you don't have an annual out of pocket max and IF 25% is your share on ANY surgery, should you have issues that make your surgery take longer your share will be higher.

For example my DH had excessive scar tissue from an ancient gall bladder surgery. He had to pay 30%. Rather than around $1500 out of pocket we were expecting it was nearly $5K. That was for an out of network facility, 2 years ago.

I have different insurance than DH and stayed in network ( after learning that lesson). I had a very large hiatal hernia repair and although my max out of pocket was $750 the insurance ended up paying $21K+ just for the hospital which was about double what it would have been otherwise. All together the surgery was around $25K and would have only been $17K(ish) if it weren't for that.

Of course you won't have to have the money upfront for unexpected thing that might crop up during surgery, but you'll still have to pay it.

If you do have a yearly max out of pocket, you shouldn't have to pay any extra if the unexpected happens.

As already mentioned, talk to the insurance company to find out if there is an annal limit, then if necessary, talk to the hospital and doctor. We hadn't even thought about the possibility of the surgery being anything but routine. And no one at either facility said "hey this is the best-case-scenario price."

I had to learn from our personal experience, maybe you won't have to.

[coolcrystal 1]

20k seems pretty high for the lap band surgery. I live in Dallas and you can find a good surgeon here to do it for 15k, which includes a year of fills and appointments in the price. Perhaps you should try to find it cheaper in your area. If you could find it for 15k, that would only be 3750 out of pocket for you and yes, it is totally worth it to take out of 401k especially if you can do a 401k loan like I did. They take the money out of my paycheck every two weeks and all interest just goes back into my 401k, so I'm just paying myself the interest. Best of luck! :angry_smile:

[oreokitty 0]

I think it is totally worth it

I almost took my part out of my husbands 401k so we could make payments on it but we ended up doing a unsecure loan.

YOur long life is worth it

I have lost 85 lbs and i feel great it was so worth the cost and I would do it again if I had to

Maybe take the check from the IRS that shoudl be coming in may and put that towards it.

I would check to see if you could find a cheaper doc but you do want a good doc and one semi close to your home for fills and check ups

[JohnC 31]

I called my insc.co. they said I have no max. on out-of-pocket expenses. Also the 75% only applies to bariatric surgery only. I'm no longer actively working & I'm not 59 1/2 years old so I can't withdraw from my 401k without a large penalty nor can I take out a loan from them. Thank you all for your replies.

[MacMadame 81]

That's too bad. I hope it works out for you.

[juliegeraci 7]

Mine paid all but $2500 plus no fills. The fills have probably run me another $3k the last 21 months. Good luck to you. It is so worth it!