Oh NO! - ThinnerTimes

smith5sm · 08-21-2007, 08:40 AM

I just got off the phone with Southern Health, (my current insurance) and they say that they DO cover it, but my employer does not.... is there anything I can do?

The I called BCBS and Aetna because of all the great things I've seen on here, and both say they don't provide coverage for WLS. WHAT???? I'm so confused? Help!

moosie · 08-21-2007, 08:42 AM

I have Aetna and they covered mine just 3 weeks ago. My dh works for UPS and has outstanding insurance. I've had 5 kids that were covered 100% too.

smith5sm · 08-21-2007, 08:55 AM

so whats the difference? Is it because I would need an individual policy? What do I do now?

moosie · 08-21-2007, 08:58 AM

Quote:

Originally Posted by smith5sm

so whats the difference? Is it because I would need an individual policy? What do I do now?

Maybe you or your hubby could get a PT job at UPS? The ins. is awesome.

Baron Patrick · 08-21-2007, 09:43 AM

The insurance contract on what is and is not covered is decided by the employer, not necessarily the insurance carrier. Blue Cross may cover WLS for one company, but not for another.

What you need to do is find out if the company you work for has a provision for WLS as a "medical necessity." Also, find out if they cover LapBand and / or gastric bypass. More businesses are allowing the LapBand because it costs less than gastric bypass. You need to ask very pointed questions and get direct answers.

I fought my insurance for two years. First they said they did not cover gastric bypass - just the LapBand, then they said they did, then the truth came out saying gastric bypass is covered as a "medical necessity". They love to play games, and give you partial information - discouraging you and hoping you will go away - I know mine wished I did!

Be prepared to fight, and don't give up!

smith5sm · 08-21-2007, 11:17 AM

thank you both for the info... as for my hubby... I'm single, and as for a PT job at UPS... I teach, and both jobs happen pretty much the same time of day, so I don't think thats a possibility.

I will keep harassing BCBS and Aetna... although I have no idea what to ask them when I get them on the phone. I'm an insurance idiot, but i guess after this, I won't be! Just not sure exactly what to ask at this point.

smith5sm · 08-21-2007, 11:24 AM

as far as my current insurance, they state that they do not cover "dietary supplements or programs for weight reduction. Medical or psychiatric services, office visits, and associated charges for procedures primarily performed for the treatment of obesity or weight reduction, including but not limited to, gastric bypasses, mini gastric bypasses, stomach stapling, gastric balloons, jejunal bypasses, gastric banding, gastroplasty, BPD-DS, and bariatric specialist services."

I don't see any loophole there. However, when I called the company, they say that they DO pay, but that the school board that I work for will not. Now what?

'thann · 08-21-2007, 11:52 AM

Insurance companies can be so infuriating. My brother is director of underwriting for a large insurance company. The bulk of his job is figuring out what treatments/operations/medical care/etc. he can cut from insurance policies to save client companies money. Money is the bottom line. Period.

Every company policy is different. I have BCBS through the State of Michigan (hubby's job). At this moment they cover GBS, but you have to jump through a zillion hoops to get approval. I am sure that part of the reason they do that is to discourage people -- it's frustrating and disheartening to make the decision to have GBS, and then wait for an entire year doing a PCP-monitored diet. It's especially frustrating because I see other folks who have BCBS in other states or with other employers who get approved almost immediately.

My big fear is that 11 months from now, when I'm through with this diet, that BCBS of Michigan will have excluded WLS.

Keep in mind that insurance policies are negotiated every year. Check back regularly with your insurance company to see what's covered.

Good luck, and whatever you do, don't despair!

'thann

Toony · 08-21-2007, 12:29 PM

That's a fear I have too... once I'm thru all the hoops, the policy will change... Maybe the 6-month waiting period is so they can hold a meeting and say, "Hey, guys... we currently have 243 people on track for wls... let's exclude that NOW and save the company millions!"

Ugh!

toony

Baron Patrick · 08-21-2007, 01:34 PM

Here in California we have the "Department of Managed Care" that oversee's the health insurance in the state. After fighting my insurance company, appealed, and went through their process, they kept coming back claiming it's not a "medical necessity".

I contacted the agency and told them what was happening. They opened a case, asked me for all the information I had, then requested info from my doctor and the insurance company. They have a team of doctors who sit down and review each case. They are impartial in that they have no vested interest in the insurance company so we can get a fair review. The best part is their decision is final, and everyone has to abide by that decision. There are no appeals or anything.

The review takes 30 days, and of course, they found in my favor, so they had to provide the surgery - period.

What am I saying? See if your state has anything similar that can help you.
It's always worth a shot!