Need to Vent

[sshaw9126 0]

My insurance has an exclusion for weight loss surgery so I am self pay. My first appointment with the doctor is Tuesday (5/6). I was really excited about the Lap Band process until yesterday.

I called my HR person at work to ask her an insurance question and she called our insurance rep to get the answer. The rep told her that I needed to be careful with getting the Lap Band since it is not covered. They told me that anything that goes wrong associated with it will not be covered by insurance either. This could potentially put my family in financial ruin. At first I was discourged but now I am mad.

I just can't believe that insurance will happily pay for things that obesity causes. They are telling me that they will pay for the high blood pressure, heart disease, and whatever else my weigh may cause. You would think that as a company, they would be happy about the fact that I am getting myself healthier.

I am now wondering if this is the right thing for me. Like most of you, I have tried and failed at every diet. I have been overweight most of my adult life. I feel like I NEED this to change my life.

[CaliGirl626 0]

Dear Sshaw9126,

I am also a cash-pay patient. My surgery is in 10 days. I would suggest you to ask your doctor (surgeon) whether or not they offer the BLIS for cash patient.

BLIS is pretty much a surgery insurance for cash patient. If you want more info about it, check out this link. Coastal Center for Obesity : Patient Support : Finance

I understand your anger. Instead of the insurance wanting to solve the problem, they just keep on wanting to fixing it from the wrong end.

Take care!

[skierhj 1]

I have the same problem, my insurance company has a specific exclusion for any bariatric surgeries as they consider them to be "elective" surgery akin to cosmetic and not medically necessary. What a ridiculous idea. By the time I admitted to myself that I needed to have the lap band surgery there were already problems caused by my weight.

The somewhat good new is that I have spoken to a lot of people with my insurance company and the only things they won't cover are specifically related to lap band and they were pretty minimal. Fills, erosion, slippage, and anything the specifically and directly relates to the band

I say it's worth the risk. The odds of running into these issues seem pretty small and the possible benefits seem to greatly outweigh the risks. I'm going in on the 21st!

[jillagin2000 1]

My insurance paid for my band 5 years ago but then I lost my job. I had to pay for fills/unfills myself (which in my experience can run from $250 to $1500 depending on your doctor and what part of the country you're in). And when my band slipped I had no insurance, I didn't realize my symptoms were from a slipped band and I suffered for almost 2 years before I could afford to be seen by a surgeon.

Then last year, my new job's insurance had an exclusion. It's the same employer more or less and the same insurance company as had paid for the initial placement but I was still paying for my own fills/unfills. But now, same employer/insurance company but a new plan, it's covered and I'm going to get a revision to RNY.

The main driver for that rather than getting my band fixed or replaced is the continued follow up. Even if my band doesn't slip again or some other complication happens I'd still potentially be out of pocket for all of the inevitable fills/unfills.

I just thought I'd share my story if that helps you with your own decision making. I do love my band and lost 100lbs with it before it slipped but I'm looking forward to my bypass too.

[NY2LAGirl 0]

Welcome to the nightmare world of health care coverage in the United States!!!!! I ran a doc's office for 6 years dealing with them everyday and they has 2 purposes in life the first is to collect your monthly billing the second is to try and avoid paying for any medical needs you have!!!! I am a cash pay too since Blue Cross denied me. I am being banded on May 13th at Journey Lite in Thousand Oaks, CA by Dr Billy (who is a sweetheart). I am paying $14,500 and one thousand of that is fills and follow-up for life so worth it! My insurance did pay for all my pre-op testing. I just submitted the bills to them and they didn't question them. SURPRISE!

I would ask your doctor what is included post-op should things go wrong for your own peace of mind! Good Luck! Stay Strong and committed.

[barbara9460 1]

As much as I hate to say it, it's not your insurance that has an exclusion, it's your company! Each company dictates what it wants covered and what it doesn't.

I hope you find the answer and that you succeed in your journey.

Barbara

[kathystrick 3]

My insurance has a specific exclusion against bariatric procedures as well, but DH's covers it. The policy is expensive, but not as expensive as being self pay. Now I just live in fear of him deciding to change jobs once I've had surgery and then all of my follow-up costs will fall on us. I will just have to cross that bridge should I come to it. I am not going to not have surgery because that might happen.

I hope you are able to find a solution that fits your situation. I agree that the position of insurance companies (as well as our employers since they decide whether or not to have the exclusion) about bariatric procedures makes no sense when you look at the big picture, but also realize that we are their captives when it comes to what they choose to cover and not. You almost HAVE to have insurance in this country to even get an appointment with almost any doctor, but any procedure ordered may or may not be covered once ordered. Catch-22.

Good luck!

[Great2BThin 5]

As much as I hate insurance, I have to agree with the poster said it wasn't the insurance company but rather the employer. My next door neighbor has the same insurance company as me, United Healthcare. Her and her husband both had surgery (bypass). My insurance, again same one as theirs, has denied it as it's an 'exclusion' placed there by DH's employer. My neighbors had a great experience as well with their insurance paying and approving everything, no 6 mos supervised diet, etc.

[MerryHearted 20]

I'm with you -- it's crazy that they'll happily pay for all the health issues resulting from obesity but not to "cure" the source of the problem.

I was so thrilled when my company changed their policy to cover it. They also cover a rather expensive physician-monitored diet & exercise program now. That amazes me.

Now, if we could just get them to cover abdominoplasty and breast augmentation... :party: haha OK maybe not. "But you'd have a lot of really HOT employees" probably wouldn't work as a good argument for it, eh?

[PennyLane 0]

My insurance has a specific exclusion against bariatric procedures as well, but DH's covers it. The policy is expensive, but not as expensive as being self pay. Now I just live in fear of him deciding to change jobs once I've had surgery and then all of my follow-up costs will fall on us. I will just have to cross that bridge should I come to it. I am not going to not have surgery because that might happen.

I hope you are able to find a solution that fits your situation. I agree that the position of insurance companies (as well as our employers since they decide whether or not to have the exclusion) about bariatric procedures makes no sense when you look at the big picture, but also realize that we are their captives when it comes to what they choose to cover and not. You almost HAVE to have insurance in this country to even get an appointment with almost any doctor, but any procedure ordered may or may not be covered once ordered. Catch-22.

Good luck!

I'm no lawyer but I've had my fair share of spars with insurance companies (one tried to write my wisdom teeth off as a non-covered pre-existing condition...which is just a little crazy). I think (although you'd have to look into it) that in your case because you have creditable coverage through your husband, and especially because his insurance covers you now, that HIPAA laws would prevent any new insurance company from denying you coverage. I'm saying this because I think you could successfully argue that the band is a pre-existing condition and those same laws apply to the lap band.

Those pre-existing condition laws (again, not a lawyer, but I believe) that you can't be denied coverage for those conditions if you haven't received medical advice or treatment for them for 6 months before your enrollment date in a new plan. Which I think would mean that if your husband does change jobs to a new employer who doesn't cover lap band stuff, wait to enroll for six months (while spending those six months away from your doctor if at all possible) and then...there you go.

Now, for all I know there are exclusions in HIPAA to things like the band but I hope not (if not, couldn't they do the same for prosthetic knees and such?). And don't people with breast implants gone bad get their removal covered? Just something to think about :frown:

[CallMeAl 0]

I have to agree with the issue regarding bariatric surgeries or "Morbid Obesity Treatments". With my insurance (UHC) if you are diabetic or have a plethora of other diseases, they require you to participate in their managed care program or they can refuse to to continue coverage. Their managed care program is speaking with one of their nurses every couple of months or so by phone.

The issue that irritates me is that they cover one "Morbid Obesity Treatment," although that includes "body sculpting" which I'm hoping is possible plastic surgery when I reach goal, and only pay at 50% unlike the 70% they pay for everything else. Plus, none of your costs count towards your yearly out of pocket maximum! However, if you are an alcoholic or a drug addict, they will pay 70% for up to 3 treatment episodes and it all counts towards your yearly out of pocket maximum. What's up with that? Obviously they don't realize the cost of obesity and obesity related illnesses.