Your insurance company is NOT the enemy.

[LipstickLady 25,682]

I know it's heartbreaking to be discover that your health insurance does not cover WLS. I know it makes no sense that they will cover complications due to heart disease, diabetes, back and knee problems, etc. I know it can be very costly to pay for all, half or part of the surgery yourself. It's frustrating and it's not fair.

That said, insurance companies don't choose to cover or not cover WLS, your EMPLOYER does. It's truly a bum rap that insurance companies take when people take their anger out on them because they can't get the medical procedures they want. ***IT'S NOT THEIR FAULT***

No, I do NOT work in the insurance industry, nor does anyone in my family. I don't have stock or any other investment in insurance and I don't benefit in any way for sticking up for them. It's simply not true.

BCBS VA covered mine 100%. BCBS VA denied my bestie because her company chose a different package. Our old insurance Aetna would only cover 75% five years ago. When our renewal came up, they covered 90%. For some people they cover 100%, for county and state employees in my area they do not cover it at all.

Companies pick insurance packages based on the cost to them. If they choose not to cover WLS, that's on them. Your insurance company will cover anything the package covers.

If you have an issue with the coverage that you are offered, contact your employer. Fight/petition/beg/plead/pester your human resources and benefits director until they make the change. When you fight the insurance company, you are fighting the wrong party and you are wasting your time.

I am NOT talking about denials, I am talking about no coverage. Please do not get the two confused. Big difference. Find out the reason, fight the reason, but fight the right fight with the right party.

[Elode 8,093]

I love my federal BCBS!! They are my best friend lol!!!!!

[JamieLogical 8,684]

That's definitely untrue in my case. The BCBS provider in my area, Excellus, does cover WLS but with ridiculous restrictions. They require a documented BMI of over 40 for 5 years with no comorbidities or over 35 with comorbidities. I lost 90 pounds "on my own" in 2010/2011, which put my BMI well below 40. I regained and re-lost and regained and re-lost my way back up over the subsequent 3 years, eventually ending up well over a 40 BMI again. However, since I just got back up over 40 in the past year, I would have had to wait another FOUR years to qualify for surgery. I felt like they were punishing me for at least TRYING to lose the weight on my own. Had I just stayed fat back in 2010, I'd have qualified for WLS this year!

Edit: Here's a link to the specific policy on the Surgical Management of Obesity. Item 1B states: "The condition of morbid obesity must be of at least 5 years duration."

https://www.excellusbcbs.com/wps/wcm/connect/7626cc31-589a-449c-8757-09ef8ac1a985/mp+surg_obes+tac+%232+13.pdf?MOD=AJPERES&CACHEID=7626cc31-589a-449c-8757-09ef8ac1a985

Edited March 10, 2015 by JamieLogical

[ProjectMe 909]

I have Tricare & have had zero problems. However I am always appalled at my work's (school,district) yearly mandatory insurance coverage meeting. It costs way too much, to the point where I sit and wonder how anyone in education can possibly afford to cover themselves let alone their families. I am reminded that the insurance industry is in business to make money...not to save lives.

My school district opts for a pkg that does not cover WLS even though 3/4's the employees are overweight/obese...

Had to add this: And until all insurance companies cover individuals with pre-existing conditions, like my 14 yr old son who is Type 1 diabetic, who will one day leave the nest and require his own insurance...they most definitely are the enemy in this mother's eyes.

Edited March 10, 2015 by ProjectMe

[ProjectMe 909]

*duplicate post

Edited March 10, 2015 by ProjectMe

[LindsB 37]

In the majority of cases this is true, but it wasn't for me. I know it may not apply to many people, but it applied to me so I thought I'd share. I have Aetna through my employer (small group <20) and when I contacted the insurance company and they said it was an exclusion I spoke with the person who handles benefits at my company. She made several calls and found out that Aetna doesn't offer the bariatric rider to be purchased by small groups in CT. So, it is possible that an employer doesn't have the option, but obviously still not a reason to fight with the insurance company over it.

[Swampdoggie 477]

I have United Healthcare thru my husband who is a government employee. They had the 6 mo hoops and covered a lot but not all. My surgeon was out of network. The only thing was that I hit the 6 mo at year end and was told I had to wait until 2015 for approval. My surgeon wanted me to call the US Office of Personnel Management to complain to them about UH because they pick the insurance options employees may select and UH has changed rules to make it harder to qualify. However, I didn't want to raise hell that could jeopardize our coverage (in this unsettled insurance environment) so I didnt call. BUT, I got the news the very same day that I'd been approved. So its just hard to say. I do think the particular account representative's predilictions and knowledge play a role and I think the relationship of the surgeon with the insurance reps also plays a role. Just me own thoughts.

Edited March 10, 2015 by Swampdoggie

[Stevehud 1,790]

Actually she is right to a point, many insurance agencies that would otherwise cover WLS do not cover it due to a specific exclusion rider chosen by the employer who offers the plan. this saves them money in their premiums, for example my wifes company excludes tufts from covering wls, so i had to pick up insurance through my company which has

tufts, because my company does not exclude anything. Now i had a hard time but that was due to paperwork issues. Now my company has just been bought out by a company in another state and they ise BCBS of tx which does cover WLS, but i checked into it to see about the panniculectomy and was told by my new company that they exclude all wls surgeries and related surgeries as well as fertility treatments, ( not worried about that lol) Now some states do not allow exclusions but they are few and far between, new hampshire is one, i think indiana, and washington, but dont quote me on those.

Edited March 10, 2015 by Stevehud

[imsoglad56 402]

In mine and my husband's case, it was the way the policy covers WLS that was the problem. They have the usual requirements, like a certain BMI for a certain length of time, 6 months medically supervised weight loss, etc., but those weren't the issue. The problem we had was that after you had met all the requirements and been approved, you had to pay the first $5,000 out of pocket before the coverage would kick in, then once it did, it only paid up to a maximum of $13,000. So after we added it up, we would have been out of pocket approximately $18,000 for each of us, which was out of the question. And that was just for the surgeon and hospital, it didn't include the anesthesia or any pre-op testing.

[Babbs 14,680]

For profit insurance is bullshit. The US needs to get on the ball and come up with a national plan like all the other industrialized countries.

*End rant*

[TEXASLADY52 264]

imsoglad56 you must work for the State of Texas? That is what I have....I paid $8,000 upfront. I had to pay the co-payment plus 20% on all the pre-tests. I then had to use a COE (center of excellent) doctor and hospital.....which I did.....but the anesthesiologist was not in network and the insurance company would not pay. Had to file a complaint with the Texas Board of Insurance to get them to pay the bill. Insurance company finally came to a settlement with them after I filed, but the bills never stop coming!!!! I had to have a IVC filter put in the day before my surgery at a different hospital.......then 90 days later go back and have it removed. I will be paying on this surgery for the rest of my life!!!

[imsoglad56 402]

@@TEXASLADY52, I sure do. I work for a state university and my husband works for TDCJ so we both have the same insurance. We ended up going to Dallas and seeing Dr. Jayaseelan at Dallas Bariatric Center. We both had hiatal hernias, so he did the hernia surgery and billed insurance for it, then we paid cash for the sleeve portion of the surgery. Instead of the 18 to 20 grand each, it has ended up costing us about $6,000 each for everything.

[TEXASLADY52 264]

That is fantastic! Hope you both are doing great! I refuse to let myself get stressed out over the bills.....I have been paying them $10 a month....each month they call and want to know if I can up my pay and I just tell them not at this time!! I probably owe at least $12,000 if not more.

@@TEXASLADY52, I sure do. I work for a state university and my husband works for TDCJ so we both have the same insurance. We ended up going to Dallas and seeing Dr. Jayaseelan at Dallas Bariatric Center. We both had hiatal hernias, so he did the hernia surgery and billed insurance for it, then we paid cash for the sleeve portion of the surgery. Instead of the 18 to 20 grand each, it has ended up costing us about $6,000 each for everything.

[imsoglad56 402]

That is fantastic! Hope you both are doing great! I refuse to let myself get stressed out over the bills.....I have been paying them $10 a month....each month they call and want to know if I can up my pay and I just tell them not at this time!! I probably owe at least $12,000 if not more.

Ouch! We were able to use our Tex-flex benefits to pay for $4,800 of the costs and have it withheld from our paychecks, pre-tax, over the next 12 months. So, come October, our paychecks will go up around $200 a month, yay! That's when we'll also pay off one of the small loans we took out and then we'll only have one loan left to pay off. I can't wait, because then I'll be able to start saving for plastics, lol.

[LipstickLady 25,682]

That's definitely untrue in my case. The BCBS provider in my area, Excellus, does cover WLS but with ridiculous restrictions. They require a documented BMI of over 40 for 5 years with no comorbidities or over 35 with comorbidities. I lost 90 pounds "on my own" in 2010/2011, which put my BMI well below 40. I regained and re-lost and regained and re-lost my way back up over the subsequent 3 years, eventually ending up well over a 40 BMI again. However, since I just got back up over 40 in the past year, I would have had to wait another FOUR years to qualify for surgery. I felt like they were punishing me for at least TRYING to lose the weight on my own. Had I just stayed fat back in 2010, I'd have qualified for WLS this year!

Edit: Here's a link to the specific policy on the Surgical Management of Obesity. Item 1B states: "The condition of morbid obesity must be of at least 5 years duration."

https://www.excellusbcbs.com/wps/wcm/connect/7626cc31-589a-449c-8757-09ef8ac1a985/mp+surg_obes+tac+#2+13.pdf?MOD=AJPERES&CACHEID=7626cc31-589a-449c-8757-09ef8ac1a985

That's the package your employer chose.