Question:
What do you make of this wording?

I received our 2004 insurance coverage book. The section for Exclusions states this: Some services or supplies you receive will not be covered under this plan. Expenses for the following will not be paid. 37. Services or expenses for treatment of obesity,weight recution or dietary control. Benefits will not be provided for subsequent surgery for complications related to a covered surgical procedure for obesity (morbid) if the complications arise from non-compliance with the medical recommendations regarding patient activity and lifestyle following the procedure. Benefits will not be provided for reversals or reconstructive procedures resulting from non-covered treatment. With all that being said. I called my insurance company and they said it is covered if it is medically neccessary. Why can't they just say that? I'm wondering if they will cover procedures for strictures?    — D. K. (posted on November 17, 2003)

November 16, 2003
It sounds like they will cover surgery. It also sounds like they are giving themselves a reason not to cover a hernia repair or any other complication after surgery that they can possibly say was caused by not following the surgeon's instructions. I think they should cover treatment of strictures, as you could easily have your surgoen say that strictures are not caused by non-compliance or lifestyle. Somewhere in there it probably does say surgery is covered for morbid obesity if medically necessary, but this is an exclusion to cover their butts so they don't have to cover hernia repairs that may include a tummy tuck. However, the way they worded this exclusion, they may very well cover reconstuctive procedures after you lose the weight.
   — koogy

November 16, 2003
I think they are saying, yes, we will do the surgery (medical neccessity) but if you do not comply with all recommendations following the procedure, you are on your own. (don't take your vitamins, don't exercise, don't eat proper foods, don't follow up with your doctor on a regular basis) They just want you to be compliant. Strictures happen, they will cover it, but let's say you were to be on a full liquid diet and you have a piece of cake stuck in your throat...(just being silly here) they will know you were not compliant. All that being said, always check with insurance, and do everything that is medically recommended. I think there is concern with insurance companies covering expenses that could have been avoided by following the docs advice. Good luck to you
   — dimpkd