Futr littl Debi

My doctor was not happy when I told her I wanted WLS. She had had only 2 patients who had WLS and neither of them did very well. But when I told her I wanted lapband and not RNY, she was MUCH happier. She now asks questions and is making sure I get any appointments set up that might cause obstacles with the approval process. I love my doctor.

You are so lucky! Congratulations! I heard from the doctor yesterday too. He is all booked up until June 2nd! I couldn't believe it...insurance approval in 10 days, but can't schedule surgery until June. I guess everything couldn't go smoothly.

You should check your policy. Usually, if WLS is covered, it is covered for over 40 BMI or 35-40 BMI with comorbidities. I would appeal the decision. They may be making the decision based on the wrong criteria. I would just point out that your BMI is over 40.

Congratulations on getting your date!! I received my approval yesterday, now I'm just waiting for the scheduler. We seem to always be waiting for something... Anyway, I would start writing down your questions and talk to your doctor. They really do have answers for you.

SecureHorizons is the Medicare product from PacifiCare. If you qualified for the surgery itself, PacifiCare used to require a 6 month telephone counseling, plus a psych eval and nutritionist. They recently dropped the telephone counseling requirement. Because PacifiCare and SecureHorizons are offered by the same company, they probably have the same requirements, but no guarantees. My doctor's office knew exactly what my insurance requirements were when I went in for the seminar. I would think your best bet would be to check with them.

Wheetsin, you are correct. Group insurance carriers are not permitted to have different provisions for individuals under a contract. Companies can buy different insurance plans for different categories of employees (officers vs. regular workers), but it has to be clear what the categories are and the purchased plan has to apply to everyone in the category. If the insurance is an individual plan, then the individual could buy a rider for their coverage that wouldn't apply to anyone else that the insurance carrier covers. But that's one of the main differences between Group and Individual insurance.

As long as you keep your Employer based coverage, you won't have any issues with portability. The problem with getting an individual plan is that the laws for individual health insurance allow the insurance company to set their rates according to your health risks. For people in our situation, that means that the rates are going to be high. Also, individual insurance companies are allowed to impose exclusions for pre-existing conditions. If they do this, you would be paying a large premium for the individual insurance along with the premiums you are paying for your 2 employer based plans. And after all that, the individual plan could probably deny coverage for weight loss surgery due to the pre-existing condition. Yuck...