asked HR why they exclude WLS: READ THIS!!

[angel1975 0]

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????

[strikeuptheband 16]

I think its Bull! They are so short sighted (ins companies in general), they can't see that paying for something preventative now will save them tons of money when they won't be getting claims later from us for our weight related health problems.

[SpecialK 22]

That is absolutely not true that most insurance companies don't cover it and its absolutely not true that Blue Cross/Blue Shield in OHIO doesn't cover it for other companies and employers because I know someone who works for the Post Office in the Columbus area and they covered her surgery. So, get the facts together on how the complications rates on lapband are drastically different that gastric bypass and go back and see that HR person and ask them to reconsider based on the FACTS.

Best wishes ....but if all else fails, check into Self Pay... its worth your health to do what you have to do.

[Carramia 0]

Hi, We asked our HR the same question and got the same answer. So we called the Insurance company itself and they do cover the surgery, but the employer has to opt into that part of the plan. Which our company was unwilling to do.

SO instead I am going to Mexico where it's almost 1/2 the cost. Getting banded Monday Aug 25!!!! My friend just did 10 days ago at the same place and said it was clean professional etc...

Good luck!

[Tess415 1]

Yes, what insurance covers comes from the contract that the company purchases from the insurance provider. Unfortunately, the way the economy is most employers are not going to pay for additional coverage if they can avoid it! I work for a healthcare system that doesn't cover any WLS, but the competitor healthcare system does. If I hadn't been covered by my DH's insurance, I was seriously considering a lateral move into the other healthcare system just for the surgery. Fortunately, my DH's insurance paid 90% after the deductible was met.

[Long2BFree 12]

I think it all comes down to cost. The employers aren't willing to pay the higher cost and I bet many employees wouldn't pay it either. I think they are trying to make insurance an affordable option.

[vegasgirl44 0]

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????

Insurance companies don't care if you lose all your co-morbidities, etc., and don't have to take meds anymore or save them money "down the road" because they are banking on the fact that somewhere soon down that road, you won't have that insurance anymore. If you have surgery, they pay for it, and then you get another job, and they are out that money.

I have BCBS of Tennessee and I suppose my company, PSI Solutions Inc. decided to opt of of that. Bummer! I had to go self pay. I got an account with CareCredit and I am already having to make payments starting Sept 10th. I don't care. To me, it's like a car payment. Say Hello to my new car, people!

[JoannMarie 0]

Interesting situation, isn't it? Wonder why Medicare started paying for WLS back in 2007? Because it has been proven to be safe and effective in the long-term health of patients and will very quickly be saving Medicare a lot of money (probably already is). But - the more insurance companies save, and don't have to pay out -- the more profit on the bottom line. They will hold out as long as they can. Sure, they make it available to employers, but at an expense level the employers are not willing to pay. They tell the HR folks the standard line - not safe - will never be covered - etc., etc. What employer will opt for that? Well, the more HR hears from all of us, the sooner it will be covered. Please find a way to let your HR people know the real story and the real statistics, as that's the only way it will happen. I've noticed over the years that once Medicare starts paying for a "new" procedure or treatment that saves the system money overall, the rest of the insurance world starts looking at it in a different light.

My friend could not get her surgery covered - she was a self-pay and HAPPY she did it! There are several financing plans out there - just about the same as the new car! If there is any way - go for it!

Good luck to all!

[vegasgirl44 0]

Interesting situation, isn't it? Wonder why Medicare started paying for WLS back in 2007? Because it has been proven to be safe and effective in the long-term health of patients and will very quickly be saving Medicare a lot of money (probably already is). But - the more insurance companies save, and don't have to pay out -- the more profit on the bottom line. They will hold out as long as they can. Sure, they make it available to employers, but at an expense level the employers are not willing to pay. They tell the HR folks the standard line - not safe - will never be covered - etc., etc. What employer will opt for that? Well, the more HR hears from all of us, the sooner it will be covered. Please find a way to let your HR people know the real story and the real statistics, as that's the only way it will happen. I've noticed over the years that once Medicare starts paying for a "new" procedure or treatment that saves the system money overall, the rest of the insurance world starts looking at it in a different light.

My friend could not get her surgery covered - she was a self-pay and HAPPY she did it! There are several financing plans out there - just about the same as the new car! If there is any way - go for it!

Good luck to all!

Joanne, AMEN, girlfriend!

[*slim* 2]

It is funny what some companies will pay for. Previously, the company I worked for had BCBS of Alabama. They would pay for gastric bypass (more risk) but would not cover lap band. Now we have BCBS of Illinois and they cover both, BUT my understanding is they make it so VERY hard to get approved. IF they approve me, I have care credit to handle my out of pocket costs. Good luck to everyone!

[circa 0]

Its hard to believe what any insurance company says. BCBS of Alabama didn't pay for birth control pills because "it is not a proven safe and effective method - it is still considered experimental" - yes, that's what they told me. The pill has been around longer than *I* have.

Companies CHOOSE to include or exclude WLS from their policies.

I'm someone who, 3 years ago, heck even 2 years ago would tell you to just back away from the table to lose weight and get on the treadmill and off the sofa. Yeah. That was until I got sick. They put me on steroids, and I have now gained 130 lbs. My body weight has almost DOUBLED. I try to get off the couch, but I can't. I'm too weak, tired and sore. Its not as easy as just putting down the junk food - I don't really even eat it. But I realize how much work it takes to be fit, and that sometimes, the physical activity needed isn't POSSIBLE. So yeah - now I'm fat, still not healthy from the illness I had - in fact, its gotten WORSE - and now I'm 300 lbs to boot. Thanks insurance company for your CHOICE in my treatment options. Arseholes.

[JoannMarie 0]

Right now I'm in a battle of my own - not as earth-shaking as many of the ins battles out there, but will be costly to DH and me... I've been on Celebrex for years for severe arthritis (everywhere). Nothing else even comes close to working, and Celebrex is the safest when considering the bleeding issues with NSAIDS over long period of time. PCP checks for cardiac issues regularly. Even with the Celebrex, I have many days of breakthrough pain that are debilitating. Since being on Medicare I have been paying Humana for my drug coverage - which has been a plus for them, since two of the three drugs I take are generic and not covered by them. Humana will not pay for Celebrex. After all the years of use of this drug (approx 10 years on the market?) it is not on the formulary. My doctor has put me on other drugs for several months as required by Humana to override their coverage refusal. Last week they denied me again. There's $110/mo out of pocket for the only drug that helps me. DH has the same problem with Lipitor - not on the formulary. (Now we're up to $200/mo for the 2 of us.) DH and I don't take many meds, thank goodness. My heart goes out to those who have to take many more. The problem with gov paid medical care is that they limit the newer - and most often the better - treatments that are available. Why should anyone research for better treatments when they won't be part of gov coverage? I am thankful MC covers WLS, but their coverage amount is so small it is harder and harder to find surgeons willing to accept MC payment. I know this is a political issue this year and I don't mean this in any political sense, so please don't misunderstand my concern. I think it is imperative that we think this issue through very carefully and consider the consequences of our actions. I worry that most people will receive seriously substandard care because the best is not on the formulary...

I apologize if I have offended anyone's political views. My intention is just to voice a concern.

[circa 0]

Right now I'm in a battle of my own - not as earth-shaking as many of the ins battles out there, but will be costly to DH and me... I've been on Celebrex for years for severe arthritis (everywhere). Nothing else even comes close to working, and Celebrex is the safest when considering the bleeding issues with NSAIDS over long period of time. PCP checks for cardiac issues regularly. Even with the Celebrex, I have many days of breakthrough pain that are debilitating. Since being on Medicare I have been paying Humana for my drug coverage - which has been a plus for them, since two of the three drugs I take are generic and not covered by them. Humana will not pay for Celebrex. After all the years of use of this drug (approx 10 years on the market?) it is not on the formulary. My doctor has put me on other drugs for several months as required by Humana to override their coverage refusal. Last week they denied me again. There's $110/mo out of pocket for the only drug that helps me. DH has the same problem with Lipitor - not on the formulary. (Now we're up to $200/mo for the 2 of us.) DH and I don't take many meds, thank goodness. My heart goes out to those who have to take many more. The problem with gov paid medical care is that they limit the newer - and most often the better - treatments that are available. Why should anyone research for better treatments when they won't be part of gov coverage? I am thankful MC covers WLS, but their coverage amount is so small it is harder and harder to find surgeons willing to accept MC payment. I know this is a political issue this year and I don't mean this in any political sense, so please don't misunderstand my concern. I think it is imperative that we think this issue through very carefully and consider the consequences of our actions. I worry that most people will receive seriously substandard care because the best is not on the formulary...

I apologize if I have offended anyone's political views. My intention is just to voice a concern.

Its not a political issue - its an issue directly affecting you. You're not a political issue to be played with. Something's gotta give. I won't get into my political viewpoints but DAMN - something really has to give. I pay good money for my private insurance and I couldn't get a procedure done that would LOWER my insurance company's costs for me - because it wasn't the standard treatment for my condition (a condition that, mind you, only 30,000 people in the ENTIRE WORLD have been diagnosed with - so yeah... I'm sure they have a "standard treatment" - anyway - I'm allergic to the typical treatment, so we went the old school way - which they did readily - well, that's not working so well. In fact, its not working AT ALL. but they wouldn't do any other treatments that are available - so instead, they're willing to let me suffer, go into liver failure, then I can have a liver transplant. Yeah. I'm quite glad i don't have them for an insurance company anymore. Fortunately, because my coverage never lapsed, I don't have to deal with pre-existing condition issues and as of next week, I'll be double covered with BCBS and Priority Health. YAY! One way or another, I'm getting this friggin surgery done AND getting my other surgery done so I don't have to worry about it anymore.

....and not to rant but I wouldn't NEED the lapband surgery if they had realized that after 6 months of the old school treatment, that I was getting worse and just done what they should have done, I wouldn't have this problem. I wouldn't have gained all this weight. I would be FINE.

[JoannMarie 0]

Circa, you are one of those my heart goes out to. I can survive arthritis. The second knee replacement will be a picnic compared to liver transplant. I am so happy for you and your ins change that will be covering your illness the way it should have been covered from the beginning. I know the LB surgery and subsequent weight loss will improve my situation enormously, allowing me to exercise again - which has been very difficult for me for the last year - and probably putting the Celebrex in the medicine cabinet for use on occasion instead of daily dosage. I hope you will be on the mend soon, and on your way to a healthy and active life again.