Question:
I have several questions about purchasing my own individual policy to cover WLS
I am researching purchasing an individual policy for coverage of WLS. After reviewing the coverages with one insurance company the medical limitations and exclusion part says that, " the policy does not provide benefits for : Treatment of obesity, unless qualified as morbid obese (clinically severe obesity)." My question is I am morbidly obese, but I am not sure I am severly obese with a 41 bmi. Does not being "clinically severely obese" disqualify me? Secondly, The pre-exisiting condition clause states: if a covered person has a disease, illness, or condition which was treated by a provider within 24 months prior to the effective date, such condition would be subject to the "pre-existing condition exclusion" section that is decribed below. The pre-existing condition exclusion will not exceed 12 months from the date benefits for a covered person take effect. A diagnosis is not required for a condition to be a pre-existing condition. Pre-exisitng condition exclusions:We will not pay benefits for services rendered for pre-exisitng conditions, unless those condition were fully disclosed on the allpication for this policy and benefits relating to those conditions are not specifically excluded. Any conditions not disclosed on the application may result in rescission or modification of benefits. I have asthma as a pre-existing condition. When they ask for a copy of my medical records their wont be any mention of a treatment for obesity. Although my weight would surely indicate that I am obese.I do not fully understand the pre-existing condition section. Do you think I can or can not get this policy and why? — ToriJ (posted on April 9, 2004)
April 9, 2004
clinically sever obesity would be the same as morbid obesity. However, the
company will likely be asking your height and weight prior to giving you
the policy. my son recently obtained a idividual policy and they
definateley did ask. If you do not list the preexisting conditions on the
application they may not pay for them and could cancel the policy. it is
saying there is a 12 month waiting period for benefits to cover preexisting
conditions. Individual policy's can be denied if you don't meet their
qualifications. the rude truth is, insurance companies are out to make
money, not to help people. I don't think they are going to fall for the
idea of people taking out policies for a few months , having WLS , then the
person cancels. and the company is out thousands of dollars.
Also, lying on the application could be FRAUD. be very careful, We don't
want to hear you are in trouble. Many companies are no longer covering WLS
at all, or are making it very diffiult to get approved with lots of hoops
to jump thru. I say try for the insurance. but be honest and up front in
answering questions, but don'r feel you have to volunteer info they are not
asking for.
— **willow**
April 9, 2004
If individual coverage doesn't work out for you, try group. Blue Cross of
Calif. states that you have to have a Federal ID #(available online), file
a general partnership agreement with the state, and document 30 days of
paying yourself and your spouse out of a biz acct. I have done all of
these and am looking to be insured on the 14th! By the way, your business
can be AVON, TUPPERWARE, ART CLASSES FOR CHILDREN. It has to be a
bona-fide business, but it can be a home based one. Good luck! Corina
— Cori I.
April 9, 2004
I've worked as a health insurance verifier and health claims examimer for
the past 6+ years with some of the largest insurance companies and medical
supply companies...The Pre-existing clause means if there is any medical
condition you have been treated for 24 months prior to the coverage
starting, then they won't cover it for a year. If you haven't seen the
doctor for obesity within the prior 24 months then it will be covered. The
asthma will not be covered for 12 months though, since you probably have
seen a doctor recently for it. This will include any medications you need
for the asthma. There is no guarantee that you will be able to get the
policy...that's up to the insurance company. Hope this helps. If you have
anymore questions feel free to email me @ [email protected]
— Robin J.
April 11, 2004
Someone in the health field answered your questions and is probably right.
The only thing is I was in the same position and the insurance company said
if I had insurance previous to their policy they would grandfather a
prexisting condition such as asthma making the "wait time less than 3
months." I suggest you ask to speak to a supervisor because some of
the Sev. Reps. gave me a lot of wrong information before I finally got it
right.
— Anna M.
April 13, 2004
What all the other posters said about pre-existing clauses is true. Also,
if the policy specifically states that WLS is not covered, it is NOT
covered and they will not pay for it. This has nothting to do with any
pre-existing condition. What none of the other posters has mentioned is
that insurability is determined by an underwriter. The underwriter goes by
very specific height and weight tables. Even with no pre-existing
conditions, the degree of obesity is a determining factor on who is
insurable. Everyone is insurable to a point. The sad fact is, anyone who
qualifies for WLS by weight (BMI) alone is probably not insurable on any
individual health policy. If the company does offer a policy it certainly
will have an exclusion clause attached eliminating any coverage for WLS or
even weight loss treatment.
I've been an insurance professional for 29 years, and 18 of them
specialized in the rescission and reformation of policies due to
misrepresentation by the client. I wish I had better news. Bottom line
is, it doesn't hurt to try, but don't try to cover anything, be truthful.
— Windy Pat
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