I was denied coverage by the insurance company due to the employers clause

[jenjen1653 0]

I'm so upset today.I got the call surgery is not an option for me. I should not be so devastated but really I am.

[Bandista 7,466]

Of course you are! But know that there are many people who had to figure out another way, like changing insurance or self-pay, etc. The main thing is you have decided to do something about your health and your future. You deserve to get the assistance you need so don't give up!

[MisforMimi 760]

That is truly sad. I would be upset, too. Is a time frame that you have to meet? Are your eligible for other insurance plans like through a spouse's or parent's (not sure of your age) employment? Could you waive your health coverage and purchase your own? Or sign up for a healthcare exchange plan (Obamacare/Medicaid) for your state? Could take out a loan and be self-pay? You may have to start thinking out of the box...sorry.

[5BeautifulDays 68]

My husband's employer's plan specifically prohibits WLS.

We got a home loan.

It wound up costing around $20K for everything including follow up, so in the neighborhood of financing a new car. My insurance covered most of the pre-op testing/psych/etc. You can do it even cheaper if you go to Mexico.

Best wishes. I hope you can find a way to get the money you need!

[Jacqbult 112]

That is TERRIBLE!!!!!!!!!!!!!!!!!! BTW, What is a employee clause?

[MaureenVA 35]

An employer clause means that while the insurance company (Cigna, BCBS, Aetna) has WLS coverage available, the employer providing the coverage opted to exclude the coverage. Generally this is a cost savings to the employer, and therefore the employees.

Open enrollment for Obamacare is soon. Try to get a plan through them. That's what I ended up doing.

[Kindle 8,667]

...

Edited September 30, 2014 by Kindle

[Kindle 8,667]

...

Edited September 30, 2014 by Kindle

[Kindle 8,667]

An employer clause means that while the insurance company (Cigna, BCBS, Aetna) has WLS coverage available, the employer providing the coverage opted to exclude the coverage. Generally this is a cost savings to the employer, and therefore the employees.

Open enrollment for Obamacare is soon. Try to get a plan through them. That's what I ended up doing.

Depends on what state you live in....I am self employed and pay for an individual health insurance plan. It specifically excludes WLS. In fact, once Obamacare kicked in, it is impossible to purchase an individual plan in my state that includes WLS. My new "affordable" care plan costs more and covers less than the old plan. But that's a whole other rant......

So I researched the hell out of the procedure and surgeons...both local and in Mexico. I went with the most qualified ones I found and felt the safest with, Dr. Ariel Ortiz and Dr. Martinez at OCC in TJ. I used the money I had been saving for two years for a down payment on a new truck. VSG was the best money I ever spent and I happily drive my 15 year old truck everyday.

If you really want this surgery, you should keep your options open, and make it happen.

[Jacqbult 112]

So how will I know if this is the case with my husbands insurance? I called Blue Care Network and they told me what I had to do in order to be approved. Would they have told me if the employer excluded WLS during that call? Good GOD, a whole new rejection reason to worry about...I am going to give myself a stroke! UGH!

[Kindle 8,667]

So how will I know if this is the case with my husbands insurance? I called Blue Care Network and they told me what I had to do in order to be approved. Would they have told me if the employer excluded WLS during that call? Good GOD, a whole new rejection reason to worry about...I am going to give myself a stroke! UGH!

The insurance company sent me a copy of my policy when I enrolled and I just read through the whole thing. The weight loss exclusion (which included therapy, counseling, diet programs, surgery and any complication) was listed. Ask for a copy of your husbands policy and check for yourself. When I was forced to purchase an Obamacare plan, I requested the written policy from every company. None of them included WLS. Turns out whole states can opt out of the WLS inclusion and mine is one of them.

[lisacaron 5,075]

Reading things like this really upsets me. There are reasons that people need this type of intervention, and in the long run the cost of health care for someone who is obese with co-morbidity issues some of us having more then one costs way more than surgical intervention for the reduction and prevention of those issues.

Peoples lives are at stake, and I don't think that everyone really understands the issues that can and do arise from obesity. That is why education and advocacy amount the WLS community is so important!

You would not deny a cancer patient chemo therapy or surgery to remove the cancer. You would not deny a cardiac patient a bypass so why deny an obese person who is trying to make a commitment to change their lives forever so that they hopefully never need those surgeries or interventions? I don't understand it....

[TatorTot 44]

DITTO to Lisa

[Eclectick 129]

How scary is that, I'm with Jacqbult..I have BCBS "Blue Choice" of Maryland, when I called they said I was covered as long as I met the requirements which I do...but I didn't go through all these test and 6 months of pre op with NUT to get a denial.

Pretty much scheduled for the day before Thanksgiving, only test I need to do is within 30 days prior to surgery medical clearance (EKG and blood work) Meet with the Surgeon on Oct. 29th to get "A-OK" for surgery and NUT for pre-op diet instructions...other than that..the paperwork will then be submitted to Insurance and she said could take up to 15 days to get approval. I am guessing those 15 days will be the worst 15 days of my life since it will also be during my pre-op diet....Probably will have a stroke!!

[Miss Mac 6,261]

My BCBS (Federal Employee) approved my surgery in two days, but I had to call them to find out. My surgeon's office had a slow process for moving forward, plus their insurance coordinator was on vacation. I am glad I called. The peace of mind was reassuring. Stay pro-active.