Purchasing New Health Insurance

[Guest kxbght]

Has anyone purchased health insurance just so you could get the lapband surgery covered? If so which one did you purchase?

My insurance through work won't pay so I was thinking about buying my own insurance.

Thanks,

Kerry

[Alexandra 55]

Kerry, there's no easy answer to this question. There are different rules and regulations in every state so what's true for one person isn't true for everyone. In New Jersey, for example, if you're even eligible for group insurance you CANNOT buy individual coverage. Your state may be different, but the laws are set up pretty much so as to specifically prevent what you're trying to do. Imagine what our insurance rates would be if people only bought plans when they needed them for big-ticket surgeries!

Check with your state department of health or department of insurance to see what your rights are with regard to insurance coverage. You may have options you don't know about with regard to appealing a negative decision by your employer or carrier. Buying individual coverage is usually not a good alternative; it tends to cost way more and have fewer benefits than group plans.

[thinkthin 0]

I did! However, I am SELF-EMPLOYED and did not have any other insurance. I live in Connecticut and researched available plans in advance to know which ones covered WLS with the least amount of hassle. I wanted Oxford. I could apply to Oxford (I'm amazed I was approved at over 300 lbs. to start with!), but I had to provide a copy of my tax return to prove that I am self-employed. Thank God that I actually did get on-board with the insurance, because in the pre-op workup, I learned I had gallstones and had to have the gallbladder removed. My insurance has been worth every penny!

[soonergirl 0]

If you are talking about individual policies, this will never happen. Individual policies will not cover the surgery for exactly the reason that you are thinking about. Insurance is a pay as you go contract, therefor anyone can get a policy, have something done and then cancel it. This does not make any economic sense for an insurance company to cover this type of surgery for less than they are expecting to bring in for premium. This is an abuse of the insurance system, which is why they will not do it.

The previous post refers to a company policy for someone that is self-employed. A lot of carriers in a number of states have stopped covering the surgery for these types of policies as well.

If you changed companies or went onto your spouses plan, they might cover it. An individual policy will not.

Good luck

[Alexandra 55]

If you are talking about individual policies, this will never happen. Individual policies will not cover the surgery for exactly the reason that you are thinking about.

Again, whether this is true depends on what state you're in. New Jersey has guaranteed access to individual health coverage, and I know that bariatric surgery is a covered item in individual policies if it's medically necessary. So a LOT depends on where you are in the U.S.

[FocusOnMBM 0]

Kerry, there's no easy answer to this question. There are different rules and regulations in every state so what's true for one person isn't true for everyone. In New Jersey, for example, if you're even eligible for group insurance you CANNOT buy individual coverage. Your state may be different, but the laws are set up pretty much so as to specifically prevent what you're trying to do. Imagine what our insurance rates would be if people only bought plans when they needed them for big-ticket surgeries!

Check with your state department of health or department of insurance to see what your rights are with regard to insurance coverage. You may have options you don't know about with regard to appealing a negative decision by your employer or carrier. Buying individual coverage is usually not a good alternative; it tends to cost way more and have fewer benefits than group plans.

I live in NJ and I am eligible for group insurance and have recently (as of today, actually) purchased individual coverage.

[Alexandra 55]

I live in NJ and I am eligible for group insurance and have recently (as of today, actually) purchased individual coverage.

If I were you I'd reconsider this. Your individual carrier might decide you committed insurance fraud and ultimately not pay any claims.

If you're eligible for group insurance, why aren't you on the group insurance plan?

[WASaBubbleButt 41]

If I were you I'd reconsider this. Your individual carrier might decide you committed insurance fraud and ultimately not pay any claims.

If you're eligible for group insurance, why aren't you on the group insurance plan?

Most ins co's will not cover pre-existing conditions (such as morbid obesity) and they won't do WLS until the policy has been in effect for a year. While I agree it is a complete and total abuse of the insurance system and it raises costs for the rest of us, I'm not sure it would be considered fraud. If the person meets the criteria for insurance, it's just abuse, not fraud.

[FocusOnMBM 0]

I don't understand how this is abuse at all.

The company I work for only offered UHC. The company also had an exclusion for WLS. I called up my insurance agent and let them know what the deal was and they said that I can get additional and/or cancel the insurance from my company and get my own. Just because the company I work for offers insurance shouldn't mean that I have to use them for insurance. There is no pre-existing limits on the policy I've chosen. The only don't cover pre-existing conditions for 3 - 6 months if I didn't have insurance at the time that I switched to them.

[Alexandra 55]

If the person meets the criteria for insurance, it's just abuse, not fraud.

That's just it: people who are eligible for group insurance are NOT eligible for individual coverage in NJ--they don't meet the criteria for insurance. Focus, you were misinformed. I just looked it up and one of the MAIN criteria for being eligible for individual health insurance (in the state of NJ, people, I'm only talking about NJ) is NOT being eligible for group insurance. Sure, you may have slipped through the cracks, but when you applied for individual you should have been asked if you are eligible for group.

If you were asked the question about group eligibility, you should have answered yes, and you should have not been permitted to proceed with your individual application. If your individual carrier decides to investigate at some point you might be kicked off the individual plan and have all your claims reversed. Under certain circumstances if you already have an individual plan you might be able to keep it if you join a group policy, but the reverse is never true. Individual coverage is NOT supposed to replace or supplement group coverage under any circumstances.

Things like this happen all the time and you may very well not get caught. I'm just letting you know what the laws are in the state of NJ. Is your company a NJ-based company? Are you a NJ resident? If both of those are true, then what your insurance agent told you is not. (Is the agent licensed in NJ?) What individual policy did you buy that didn't ask if you're eligible for group?

[FocusOnMBM 0]

Oxford Liberty pos i think. Ill verify when i get to the office. Im on my phone in dr office

[Alexandra 55]

Here's the pertinent portion from the Oxford Liberty individual application:

Eligibility Requirements

1. Eligibility requirements are determined under the Individual Health Coverage Reform Act of 1992, P.L. 1192, c. 161.

2. You must be a New Jersey resident.

3. You and any family members you wish to cover must not be eligible to be covered under:

(a) a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan; or

( Medicare. (See eligibility requirements in item 5 below)

By completing the application and submitting it one is attesting that the above requirements have been met. If that's not true, it could be considered a fraudulent application and the contract rendered null and void.

Just a word to the wise.

[FocusOnMBM 0]

I'll research this information further. I appreciate your input. Question.

What happens if I'm eligble for multiple group insurance? Such as, what if I worked for a company that provided UHC and I was an officer for another company that offered say, Oxford?

Can I then choose?

[Alexandra 55]

I'll research this information further. I appreciate your input. Question.

What happens if I'm eligble for multiple group insurance? Such as, what if I worked for a company that provided UHC and I was an officer for another company that offered say, Oxford?

Can I then choose?

If you're eligible for more than one group plan you can choose one or the other, or even be covered under both (though only one can be primary). This situation is unusual though: you have to be working 25 hours or more to be eligible, so if you're just an "officer" at a company you might not meet the requirements.

(BTW, I'm a NJ insurance broker so I'm actually speaking from knowledge and experience. Just in case you were wondering.)

[FocusOnMBM 0]

I work 40+ at the company I employed at and 25+ at each company I'm an officer at which is 2. Thanks for this information.