angel1975

I have supplemental insurance through aflac. My primary insurance excludes WLS. I called aflac to see if they would approve wls surgery. It is not excluded in my policy unless it is elective or cosmetic (aflac). I told the rep that my dr. said it would be medically necessary. I wanted to know how I would go about filing a claim to get approval or denial for surgery. She said that I would have to have surgery first, then they would review my case to see if it was covered. ??!! HUH that doesn't make sense. Why can't you review my medical records and go by my dr.'s referral. I asked her if I had to have life threating illness, diabetes, overweight by 100 lbs or more or bmi over 40. She said that there is nothing to go by. You have to have surgery and then we will review your case. How could you not be given approval or denial before surgery. So, I would have to self pay then submit my claim to aflac and see if they pay! Has anyone been approved by aflac?? :wink2:

yes, aflac does cover surgery. I have a sickness/hospital indemnity policy. However, for the surgery to be paid it has to be a sickness. It will cover surgery unless it is elective or cosmetic. The rep could not define what "sickness" you have to have to be covered for wls. If wls is medically necessary then I don't see why it wouldn't be covered. But, my problem is that they will not give approval or denial for surgery costs until after surgery. I just don't understand why. I am not looking to get paid for time off work as I have enough vacation and sick time to take leave. I also have short term disability insurance through them. I know they will pay me if it is covered, but that's not what I'm looking for. I'm wanting to know why they can't give approval or explanation of "sickness" as it is relating to weight loss.

Today I talked to a woman from our HR Dept or Risk Dept and she said that "all WLS are excluded because insurance companies didn't want to be responsible because they are considered high risk for complications and death and people were suing insurance companies." She also stated "that no insurance companies will cover any WLS." WHAT????? From what I've been reading this is not true. WLS have come a long way and there are proven facts and research that show these procedures to be beneficial. I know this rider was put in our insurance most likely because of the cost to the company. I think I'm going to ask her to put it in writing as to why we don't have the coverage for WLS. By the way, I have Anthem BC/BS Ohio, Blue Access plan w/ exclusions. Exclusions were not originally included in our insurance --only for the last maybe 5 years I'd say. :thumbup: What to do????

My policy w/ anthem bc/bs does specifically state it does not cover wls regardless of the reason. I just wondered if anyone every appealed this and what result did you get.

I have also talked to them multiple times and even called a Bariatric Surgeons office to see if there was anything I could do about the exclusions and the receptionist told me NO. I asked the cost of self pay and she said it was $25,000.00. I didn't even ask if that included fills. I would consider self pay if I didn't have to pay for student loans and college tuition. Sucks!!! :thumbup:

I called customer service a few times last year and was told that wls was totally excluded from my policy. Employers choice. I called the other day 08/15/08 and was told it was covered if medically necessary. I went to anthem.com to review my coverage plan and it states that wls is excluded for all purposes. I again called customer service today 08/19/08 and they told me it was excluded. I still plan on consulting w/ a surgeon about this. I will try to appeal if I get denied. Does anyone else have this plan??? Any luck w/ exclusions or appeal process???? anthem bc/bs ohio blue access ppo