amanda2008

If an insurance says all treatments for obesity are excluded, does that include WLS? My employer's insurance excludes WLS but specifically says surgery is excluded. I was thinking of getting a supplementary student plan through my university and found this under the list of exclusions: "For treatment of obesity, regardless of the history or diagnosis, including, but not limited to the following: weight reduction or dietary control programs; prescription or nonprescription drugs or medications such as Vitamins (whether to be taken orally or by injection), minerals, appetite suppressants, or nutritional supplements; and any complications resulting from weight loss treatments or procedures" Is this yet another WLS exclusion? I had a glimmer of hope and am wondering if, because WLS is not SPECIFICALLY mentioned like in my other plan, if it could possibly be covered.... thanks, I'm so desperate.

congratulations!

Thanks Gill... when did you apply for the surgery? Did you have to cancel your first policy, or can you have two?

No, I don't know anyone who works there in my region. I thought it was illegal to deny something based on pre-existing, if the person has had continuous insurance coverage?

My current policy has an exclusion that my employer won't get rid of... so I am thinking about getting a second, part-time job. Someone recommended a national chain where you can get benefits by only working part-time AND their plans don't have WLS exclusions. I have to work there three to four months before the insurance kicks in, and then what do I do? Can I apply right away for WLS, or will an insurance company not approve someone new to the plan? the coverage is with AETNA.

I believe it is excluded by my employer. I asked them to add it and they said no because it would cost everybody more money, and they shouldn't have to pay more money for something only I wanted. So my specific policy excludes it. HOWEVER I wish they would use their common sense to see that the surgery would prevent a lot of expenses that the company WOULD have to pay for it.

It depends on the plan. I don't think all companies exclude it totally from all their plans. I have United Health Care and on my policy it is excluded. I work for a small company (fewer than 15 people have the policy) and I'm sure they chose the cheapest plan possible. Not all people who have UHC have exclusions as you can see from this board. Exclusions should be ILLEGAL.

In the denial letter they said I could appeal. I was just wondering if it was a waste of time, or if anyone had ever successfully overcome an exclusion.

I think I have a good case because I have so many other health issues caused by obesity. They rejected the request pretty quickly however. Should I bother appealing? Has anyone successfully appealed and won?

I posted earlier about problems with my insurance. I decided not to switch to a private pay but instead asked to borrow the money from my company. But they want me to wait a few months before they will pay for it for a few reasons. I have gallstones and have had some problems with them over the years, mainly nausea. Both my mom and my older sister had theirs taken out and I thought I would ask my doctor if he would do both at the same time. He said yes provided the gallbladder is "not too sick." So I am going in for an ultrasound on Oct. 12. If I get them done at the same time, it seems the insurance company may pick up the tab for the anesthesiologist, etc! which would save several thousand dollars, and my company wouldn't make me wait a few months. I'm kind of confused - I think the ultrasound has to show gallstones but not too many gallstones that he won't do the Lap-Band at the same time? In the past I have done gallbladder "flushes" to pass stones. Should I do this again before the ultrasound?

I posted earlier about problems with my insurance. I decided not to switch to a private pay but instead asked to borrow the money from my company. I may be getting my gallbladder out at the same time, in which case, it seems the insurance company may pick up the tab for the anesthesiologist, etc! which would save several thousand dollars. I have gallstones and have had some problems with them over the years, mainly nausea. Both my mom and my older sister had theirs taken out and I thought I would ask my doctor if he would do both at the same time. He said yes provided the gallbladder is "not too sick." So I am going in for an ultrasound on Oct. 12. I'm kind of confused - I think the ultrasound has to show gallstones but not too many gallstones that he won't do the Lap-Band at the same time?

This is their only mention of weight loss surgery in the exclusion section of this policy: "No benefits are payable for expenses which:... Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity." Which seems like a normal exclusion saying they won't pay for anything just for cosmetic reasons. I'm wondering about pre-existing conditions - would this even apply for WLS? isn't one of the requirements be years of being overweight?

thanks Candle, I looked up plans on ehealthinsurance.com. It looks like I can get my own plan at UHC that does not exclude the surgery! I am going to apply... I wonder if they will approve me, knowing that I am switching from a group plan to an individualized plan?

Can you ever overcome exclusions (via avoiding other surgery?) WLS is (but of course) excluded from my insurance (United Healthcare). However, I have a chronic back problem and now a knee problem caused by a rotated pelvis that is not going away despite two years of physical therapy, and will likely be alleviated by losing a lot of weight quickly. The pelvic problem also prevents me from exercising normally (making it difficult to lose weight by normal means). If the doctor signs off that the WLS will avoid me having back surgery and eventually knee surgery, do you think I have ANY chance of getting UHC to pay for WLS? You would think the insurance company would be smart and see the cost benefits of avoiding much more costly surgeries with an inpatient stay, but after reading all these stories of denials, I wonder.

Yes, I was thinking of Medicaid. I don't know if I am eligible for that though.