Fighting insurance, is it worth it?

[KMCD 0]

Hi all, I have a question. I was resigned to self-paying for my band. I've got it all worked out. However, now my mom and my Aunt are saying that I should be able to fight my insurance company and get them to pay for it. My thought is that when I signed on to my current job, the first thing they made me sign in the insurance coverage was that I understood that they would NOT pay for WLS of any kind. It is pervasive throughout their literature. So, I figured, what was the point in trying to fight it?

Am I giving up too early? I really don't want to jump through the hoops of fighting these guys when I have less than a 1% chance of winning the fight. My BMI is 38, my BP is still normal (high for me though), I don't have diabetes yet and really my only co-morbidities are asthma and PCOS. I have about 70 - 80 pounds to lose and I'm getting it done so that I can keep the darn weight OFF!!!! I have gained and lost so many ridiculous pounds througout my life...what a pain! Thanks for the input...

[MissBS 3]

Hi. Of course I don't know what is best for you. If your BMI is under 40, you don't have any co-morbidities, AND your insurance says they won't cover it.... I might say that you should go ahead and pay for your surgery IF you can. If you think you have a chance of getting them to pay for it, and it wouldn't take too long to find out, you might want to give it a try. I was self pay and boy was it easy and quick. I had my initial consultation on 8/13/08 and my surgery was then scheduled for 9/12/08 (actually had it done on 9/19). I just had to have an EKG and some blood work done and then I was ready. I'm not saying the fast way is always the best, but it was the best for me. I'm not a good hoop jumper. I have issues with insurance companies.... but that is a whole other story . If you decide to pay for your surgery yourself, make sure the place you choose has a good follow-up plan included in the price you pay (visits, fills, etc). I went through True Results in Houston and I am so happy with the treatment that I have received. I do wish you good luck. Do what you think is best for you. Becky

[MacMadame 81]

If your company had a weight loss exclusion, that means they didn't pay for the coverage. There is nothing to fight then. It would be like fighting to get your house fixed after a flood when you didn't buy flood insurance. OTOH, if they do cover WLS but are just saying you aren't eligible, then it's worth fighting.

[oyesican 0]

KMCD - My 2 cents worth...YES! I was denied 2x and I used www.obesitylaw.com (Kelly and Walter). They were able to get the denial reversed. It costs nothing to have them review your policy and stats, and if they don't think they can help, they will tell you. My appeal was paid for by Allergan, it cost me nothing although it does take a while. I, like you, am sick of losing this same 80 lbs. I was denied because I haven't been fat enough long enough - they had a 2 year restriction. It took a few months but I was banded 3/9/09. I was not so concerned about the initial self-pay as I was about any future complications. It's good peace of mind knowing that all future issues, if any, will be covered as well.

Good luck to you!

[KMCD 0]

Thank you so much for all your replies! I went straight to the obesity law website and sent in an inquiry. However, I have little hope that it will work since they say that exclusions are the hardest to overcome in their FAQ section.

So here's my next question. What if you have a complication (port flipped over, erosion, etc)? Do you have to self-pay that as well if your policy excluded you from having the surgery in the first place?:scared2:

I still feel that I need this surgery, but my resolve is weakening. I am so afraid of complications. This is why I chose the doc I did. He has very few complications...

Thanks for the help:sad:

[Jaffa 5]

You could look at the positive nature of this problem. Since you are going to be self-pay anyway, you could go straight for the gastric sleeve. In reality, if the gastric sleeve was paid for by insurance companies like the band, the gastic sleeve would probably be more popular and more frequent.

Your asking the right questions....and my response is because you are asking about future complications and costs. With the sleeve they are mostly covered from the beginning, as that is when complications happen with the sleeve. With the band the dirty secret is that complications and problems will almost always result after they are covered by the surgeon, and if your self pay, then you will have to pay from it. The only exception to that rule is if it is an emergency like a slipped band causing you to not get any Water....but then they usually just take it out, and now your screwed all over again.

[KMCD 0]

You could look at the positive nature of this problem. Since you are going to be self-pay anyway, you could go straight for the gastric sleeve. In reality, if the gastric sleeve was paid for by insurance companies like the band, the gastic sleeve would probably be more popular and more frequent.

Your asking the right questions....and my response is because you are asking about future complications and costs. With the sleeve they are mostly covered from the beginning, as that is when complications happen with the sleeve. With the band the dirty secret is that complications and problems will almost always result after they are covered by the surgeon, and if your self pay, then you will have to pay from it. The only exception to that rule is if it is an emergency like a slipped band causing you to not get any Water....but then they usually just take it out, and now your screwed all over again.

Wow! Congrats on your weight loss to date!!! How impressive. My concern about the sleeve is that it is much more invasive and permanent. Plus, doesn't it cost about double the amount as the band? Really good thought though. I'm going to research both a little more closely and see what I get.... Thanks!

[MacMadame 81]

So here's my next question. What if you have a complication (port flipped over, erosion, etc)? Do you have to self-pay that as well if your policy excluded you from having the surgery in the first place?

Yes, you do. Anything involving the band, the insurance company makes you pay for. If your complication is more general -- like getting a blood clot, then it's harder for them to deny paying for it. After all, anyone can get a blood clot at any time -- they can't prove 100% it was the surgery that caused it. Some some will pay and some will not for those kinds of complications.

My concern about the sleeve is that it is much more invasive and permanent. Plus, doesn't it cost about double the amount as the band?

The lap-band is touted as being so much less invasive, but I don't agree. It puts scar tissue on your stomach and can cause all sorts of problems which may or may not go away when its taken out. How is that not invasive? If you get permanent scars, that is permanent.

I think all WLS is permanent and should be approached that way. If you take out the band, you gain back the weight. So if you want to solve your weight problem permanently, you need to think of this as a permanent solution.

Now, don't get me wrong. I understand where you are coming from because I was once there. WLS seemed so scary because I'd heard all these horror stories about RnY. So the lap-band seemed "safe" and, if something went horribly wrong, I could get it taken out. But after being on this site for a while, I realized that all the stuff that goes horribly wrong with the band are caused by the band itself. And that I had to be willing to commit to permanent, if I wanted this to work, whether I got a lap-band or not.

Once I was willing to commit to surgery and permanent, losing the part of my stomach that was causing me so much trouble didn't seem quite so extreme as it did when I first started my journey.

As for cost, my surgeon charges about 14,000 for the band and 17,000 for the sleeve both including a certain amount of aftercare. But once that time is up, the after-care for the sleeve is just annual labs. After care for the band is forever. To make it work right, you need to get fills when you start to get hungry again and that can happen at any time. So when you add in the cost of fills, the band and sleeve are very comparible in price.

The band has a higher risk in the first 3 months after surgery but after that the risks are much less than with a band. New studies have come out showing that anywhere from 25 to 40% of bandsters end up with complications requiring a resurgery -- including removing the band and revising to another surgery -- within 5 to 10 years after it being placed. Those stats were a deal-breaker for me.

[KMCD 0]

Yes, you do. Anything involving the band, the insurance company makes you pay for. If your complication is more general -- like getting a blood clot, then it's harder for them to deny paying for it. After all, anyone can get a blood clot at any time -- they can't prove 100% it was the surgery that caused it. Some some will pay and some will not for those kinds of complications.

The lap-band is touted as being so much less invasive, but I don't agree. It puts scar tissue on your stomach and can cause all sorts of problems which may or may not go away when its taken out. How is that not invasive? If you get permanent scars, that is permanent.

I think all WLS is permanent and should be approached that way. If you take out the band, you gain back the weight. So if you want to solve your weight problem permanently, you need to think of this as a permanent solution.

Now, don't get me wrong. I understand where you are coming from because I was once there. WLS seemed so scary because I'd heard all these horror stories about RnY. So the lap-band seemed "safe" and, if something went horribly wrong, I could get it taken out. But after being on this site for a while, I realized that all the stuff that goes horribly wrong with the band are caused by the band itself. And that I had to be willing to commit to permanent, if I wanted this to work, whether I got a lap-band or not.

Once I was willing to commit to surgery and permanent, losing the part of my stomach that was causing me so much trouble didn't seem quite so extreme as it did when I first started my journey.

As for cost, my surgeon charges about 14,000 for the band and 17,000 for the sleeve both including a certain amount of aftercare. But once that time is up, the after-care for the sleeve is just annual labs. After care for the band is forever. To make it work right, you need to get fills when you start to get hungry again and that can happen at any time. So when you add in the cost of fills, the band and sleeve are very comparible in price.

The band has a higher risk in the first 3 months after surgery but after that the risks are much less than with a band. New studies have come out showing that anywhere from 25 to 40% of bandsters end up with complications requiring a resurgery -- including removing the band and revising to another surgery -- within 5 to 10 years after it being placed. Those stats were a deal-breaker for me.

So, I am assuming you ended up with the sleeve or gastric bypass? You make some really terrific points and I absolutely appreciate your candid opinion! I think with all my misgivings, it's time to call the doctor again and get more info. I completely understand what you mean by the lap band and the idea of permanence in WLS. I started asking questions because I want it to be permanent. My doctor says that about 4% of the patients in his entire practice will experience slippage or erosion. I'm just not sure I can get someone to do a sleeve on me if I don't have a higher BMI. I really don't want gastric bypass because I don't want to deal with the issues of B12 and all. Thank you for the input. It has really meant a lot to me.

You are so close to you goal. How great that must feel!!!!! I would really like to hear more of your story...