I am really looking into getting the surgery. I live in SETX and the doctor who performs the surgery here is Felix Speigel. Of course, you have to have an insurance that allows for the procedure in the policy. My question is, how do you know which insurance companies will pay for it before participating and paying them their premiums? Also, is there a way to get approval for the surgery even if your policy doesn't cover it? If so, which insurance companies should I be looking at? Please help!!!

Hi Raggedy Ann,

Two good places to start your search are BandstersInsurance on the YahooGroups website, and ObesityHelp.com. Both sites have databases with records of what insurance carriers have paid for weight loss surgeries. Be sure to look ONLY in Texas, because what is true in one state may not be true in another, even if it's the same national company.

The other thing to do is ask your doctor's office which carriers are friendly to weight-loss surgery. In my experience, unless there is a specific exclusion for the treatment of morbid obesity, most carriers cover that as a disease like any other. They will have criteria to meet in order to qualify patients for treatment, and that criteria can vary considerably from place to place and doctor to doctor.

Are you employed or are you seeking individual insurance? If the latter, call your state's department of insurance and ask what the rules are in your state for individual coverage. Or you could always call an insurance broker for that information. In any event, you are asking lots of questions that will need answering, and there's no easy way to get the answers. It takes lots of research.

Good luck!!

Alex, you explained that absolutely accurately. It is a very difficult path. I knew my insurance company woundn't cover it and never really tried to fight it. Just seemed like a lot of work for an iffy result. I briefly sought out other companies for private insurance but a lot of those plans specifically refused to cover obesity problems as well. I simply called individual companies and they sent me pamphlets and books about their coverage for a private policy. I live in Oregon, not Texas so maybe things might be different there. Best of luck to your search, Teresa

Don't make the same mistake I made 2 years ago. I went to the weight-loss center first, without contacting my insurance myself, to find out if they even cover the surgery. Well, at the center I had to pay upfront $175 to the doctor and $75 to the hospital only to find out within the same day, my insurance decline treatment, because of exclusion in the policy. Well I kept in contact with the insurance company every year; because they make changes in the policy annually and this year weight-loss benefits are included. So now I'm banded as of Monday. My insurance is thru my job and it's BCBS of Oregon PPO plan.

I am a patient of Dr. Spiegels and he is wonderful I unfortantly didn't have insurance and because I was over 250 pds my premiums would have been outragous so I got a loan and pay 324 a month it was worth it to me. Good luck. Ginny

4/19/04

299/269/130

Dr. Spiegel

Thanks to everyone who answered my questions. I do currently have insurance but morbid obesity is an exclusion in the plan. My husbands insurance company also excludes this. I didn't even know where to begin. So, maybe some of your answers will help me get started!!

Thanks Again!

Raggedy, if both your and your husband's employers' policies exclude this, ask yourself the following questions:

1. Is either company self-insured, or are these off-the-shelf policies? Does either company have more than 500 employees?

2. Is what you're reading to find the exclusion a standard policy issued by a large insurer? By that I mean the following: a LOT of policy documents include a long list of exclusions that may or may not apply to you specifically. Carriers to whom this might apply are those with multi-state coverage areas, like United, Cigna, Aetna, and so on. State rules always overrule a carrier's standard plan, so if you think there's any chance this is the case check with your state to see what is and is not permitted to be excluded.

3. If the answer to 1 is yes, you can try calling your company's human resources office to see if there's anyone internally you can send an appeal to.

4. If the answer to 2 is yes, more research is needed. You should find out what your state department of insurance requires carriers to provide and what they're required to do in terms of appeals and so on. It may be possible to find someone at the department of insurance who can help you with this specific problem.

Good luck!!

Raggedy Ann and Ginny,

I was just wondering about where you both live. I live in Lumberton and was going to use Dr. Spiegel but decided to go to Houston and use Dr. Spivak. I would love to meet other people from around here that are banded or plan to be banded. Do either of you know if there is a support group around here. If you would like to e-mail me my e-mail address is falbc@lit.edu.

Now Reggedy Ann,

What kind of insurance do you have and can you change it?

Here is info on the support group in our area.

COME JOIN IN OUR FREE LAP-BAND SUPPORT GROUP

TLC- Texas Laparoscopy Center and Rennaisance Hospital will be hosting the first meetings of our Lap-Band patient support groups in July. There will be 2 meetings per month, one held in Southeast Texas and the other in Louisiana. If you are unable to attend the Texas meeting please feel free to join us in Lake Charles and vise versa!

The Texas meeting will be held on Thursday July 8, 2004 at 5:30pm.

Holiday Inn Park Central

2929 Jimmy Johnson Boulevard

off Hwy 69 in Port Arthur

If you need driving directions to the Holiday Inn Park Central please contact them directly at (409)724-5000.

The Louisiana meeting will be held on Thursday July 22, 2004 at 5:30pm.

Isle of Capri Casino

Six Palms Ballroom

Please contact us today at (409)719-0009 to reserve your space.

Monthly meetings in Texas will be held every 2nd Thursday of each month and Louisiana meetings will be held the last Thursday of each month at the above locations. You will still need to register for the support group meeting of your choice each month by calling our office as the ballroom availability may change.

Thank you, and we look forward to seeing you there!

CatheyFalb, Hi, I was banded by Dr. Spivak on 5/26. He's the greatest! He knows his stuff! I had United Healthcare Ins. He uses Park Plaza Hospital. Patients stay one night. I had other "problems" that he took care of during my surgery. He removed my gallbladder, some previous surgical adhesions (internal scar tissue), and found and removed a benign tumor on my esophagus (that I didn't even know I had, but would have become cancerous if remained). Because of these, I ended up staying an extra night. I went in to see him for my post-op today. I've lost 24 1/2 lbs. I didn't get a fill today because I'm losing well. I'm walking 2 miles a day (in our humidity!) Before, I was basically a couch potato.

CathyFalb, Sorry, I misunderstood your post. I thought you were looking for a band dr. But you've already had your surgery and seem to be doing great! So you already know how great Dr. Spivak is.

To those of you who were wondering, my insurance policies are both under 500 employees. My insurance is with Principle & Health Smart. I just have the general handout, but it does state that morbid obesity is excluded. My husband has United Healthcare, and I called the number on his card and his policy also states that morbid obesity is an exclusion on the policy. Should I call someone else other than the number I have on the cards to inquire about morbid obesity being a exclusion on the plan? For those of you who chose Dr. Spivek was there any one thing that made you choose him over Dr. Speigel? Just curious. Anyway, thanks for all your help!

I do not know anything about Dr. Spiegel. I researched Dr. Hadar Spivak quite thoroughly. His website is www.lapsurgery-net. He's been doing many different laproscopic surgeries since 1990. Has put in over 700 lapbands. He's published several articles about it and does seminars to teach other drs. I wanted someone who had been doing this for a while and knew their stuff. He has two free support groups -- meet in Park Plaza Hospital and also in San Jacinto Hospital in Baytown. He took his time answering all my ?? His staff is great. He operates out of Park Plaza Hospital in Houston. Patients stay over one night.

Most patients do NOT have the additional problems that I had. It took 8 months for my insurance to approve. During my surgery, he also removed a bad gallbladder, several adhesions (internal scar tissue from previous open method kidney removal), found a tumor located right above where the band is located -- on the esophagus/stomach juncture and removed it. Fortunately the gallbladder and tumor were benign. He said the tumor would have definitely become cancerous and much larger if remained. And put in my Lapband. Even though he tunnelled all across my abdomen, this was done laproscopically. It really makes a difference in your healing time. I was sent home with an abdominal drain for one week (this is not the normal for just a lapband surgery.) I had no complications. He knows your internal anatomy. I honestly feel that God, he, and doing this surgery could have saved my life. This tumor would not have been found unless someone were looking specifically in that area.

Wow, sorry, this is more info. than you probably wanted or needed. Feel free to PM me if you have any other ??? Best of luck!

I had Unitedhealthcare PPO and it was not excluded. Also on the Smartbandsters board they have talked about a lawyer that has successfully fought insurances that have claimed exclusions and has won many, many times. You might want to join that group and ask some questions about him.

I also want to add that I only had their insurance 3 months when they covered it and not only my surgery, but my daughters as well on the same day. So they were out a considerable amount right up front, and I have never had a problem with it other than proving my daughter was still in school, but that is taken care of now.

Raggedy, call your dept of insurance and ask if there are any standards for carrier plans in your state. Find out if you have any recourse with regard to appeals of exclusions, and who you should appeal to.

There is a department of insurance in every state, and a body of regulations that govern health plans. Find out what set of regulations govern yours and read it. If nothing else, someone at the Dept of Insurance will be able to tell you if you have options for appeal or if, really, there is nothing you can do. But I doubt the latter is the case.