Question:
I have an exclusion to bariatric surgery in my insurance coverage.
I have Blue Cross/Blue Shield of New Jersey. I was denied surgery because of an exclusion in my insurance coverage. Does anyone have any suggestions? I know a personal loan is an option, but would like to use that as a last resort. I was thinking about canceling my work insurance which is $100 a month and look for insurance on my own. I'm not sure where to start. Any help would be appreciated. — sweetcheeks194 (posted on July 22, 2008)
July 22, 2008
Insurance companies can be a pain in the arse.
I don't think cancelling your work insurance is a good idea however because
getting your own is likely to cost a lot more, and also, your new insurance
is likely to exclude WLS as well.
It's certainly worth looking into however .
Another idea is to write a lettter to your insurance company challening
their decision. ALso, make sure you've talked to the right person and that
your have correct info.
My insurance company (United Health) gave me all kinds of conflicting
information. It took me several phone calls to even be satisfied that the
person I was talking to knew what they were talking about.
Good luck.
Chris
— cjjordan
July 22, 2008
I also have BCBS but mine is BCBS of IL. I live and work in Oregon but
because my companies headquarters are in IL thats where my policy comes
from. I am also trying to get approved with BCBS and was denied initially
because I did not have enough documentation, however it is not a excluded
benefit and I have to jump through alot of hoops to get approved. It has to
be medically necessary and I have to complete a 6 month supervised diet and
exercise program with my dietician before they will re-submit for approval.
I think first and foremost you need to remember that the exclusion is not
always on the insurance companies part but your employer may not have
wanted to pay for that benefit so it may not have been included in the
policy they bought. Might want to check the specifics with your HR
department. I had cigna years ago when i was with another employer and I
was told by HR thats its a rather expensive benefit to have on there and
they ended up removing it since nobody was using it. This affected me
because I was 3 months into the process of getting all my testing and stuff
done and they took it off the beginning of the year so I was left holding
the bag. I think the worst thing you can do is to just drop your coverage,
maybe if you speak to your HR folks they can find a loophole or you can
suggest they put it on there when the time comes to renew. A personal loan
is a good option if you have exhausted all other efforts but be sure you
can pay it back since its going to be a large bill with the pre-op visits,
the surgery, anetheliologists fees, and all your post-op visits. One other
thing, if you are married maybe your spouse has a different insurer and
maybe they can add you to the policy to see if they will pay for it or if
its even a covered benefit.
Hope that helps.
Good luck!!
— jenbn
July 22, 2008
I work for a county in Texas they are self-insured but do use an
administrator - Trisurant. I went before the commissioners court and plead
my case and had all kind of documentations from doctors and such. they
lifted the exclusion and the ins paid for my surgery. Good luck to you
— bikermama
July 22, 2008
If you end up going the personal loan route...I'd tell you to seriously
consider having it done in a foreign country. I have seen a few people out
here who went to Mexico and were happy with their surgeon and hospital. I
had mine done in Belgium (because I was living there...and my BCBS plan
paid for it w/o making me jump through a single hoop except having a BMI of
40+! Less than one month for approval!) and the total cost to the insurance
company was slightly less than $15,000...the dr is Belgian but speaks
English like an American and the hospital was fantastic. He has some sort
of plan for Americans coming to Europe that they go to Portugal and his
package includes hotel for the patient and one person accompanying him/her
for the post-surgery stay...and maybe a day or two pre-surgery...I can't
remember exactly everything the package includes since I didn't get the
package...but it's worth checking out. Thailand, India and Malaysia are
also good options.
Before you do that though...I'd definitely take someone else's suggestion
and talk to your employer. I'd guess they're right that it's a surgery
excluded by your employer, not BCBS...and you might be able to convince
your employer to add it back in for you. If you talk to them, list the
benefits to them...a happier, healthier employee, less sick leave used for
any medical issues you have due to your weight, things like that.
Good luck.
— Hollywog
July 22, 2008
Welcome to my world, sorry to say I don't have any suggestions.... just
letting you know you aren't alone.
I had BCBS of Florida and had to pay $18,500 out of pocket for the same
reason. I would do it over again tomorrow. It is a lot of money, but a
drop in the bucket to save my life.
I don't know much about insurance as I have always been covered under my
husband's, but I don't think giving yours up is a good idea.
Check it out thoroughly.
Dawn Vickers, RN, BLC, CLC
— DawnVic
July 22, 2008
As a self-insured person, I'll tell you - DON'T DO IT!
First of all, as a morbidly obese person, your insurance will be insanely
expensive (we pay way more than our mortgage for our family of 4 because
I'm MO.) So I'll guess you are probably looking at at least $500 more per
month just for yourself. For that price, you will get significantly worse
coverage (much higher copays, no dental).
Not to mention that the process of getting the insurance will be demeaning
and a pain in the butt.
In the next election, I will vote for the candidate that will most likely
bring about insurance reform. Insurance is destroying us financially. I
would love to see the insurance companies be forced to carry a group plan
for self-employed people that has the same bargaining power of a large
corporation. I'm not asking for handouts, just fairness.
— fairysaddle
July 23, 2008
The loan is probably your best option if you want to go self pay and don't
want to keep fighting the insurance company.
If you want to look for different insurance go for it, but do not discard
your current insurance until after you have the new policy. If you cancel
your work insurance BEFORE you have a new policy in place, you run the risk
of having all of your current medical problems being considered
pre-existing by the new insurance when you get it. That means the
insurance would not have to pay for any visits for any condition you
currently have for a full year. Think about if you can afford to pay for
all visits, tests, and Medications on your own for a full year for all
chronic medical conditions you may have.
— redbedhead
July 23, 2008
I have BC/BS of New Jersey and I was approved.....I do have a part of my
ins. card that has " BlueCard PPO"
I had to have proof of a 6 month WL program, but I had my surgery last
March.....
I would look into why it is an exclusion, and see if medical issues can
have a better impact, on getting approved. Fight Fight Fight, Don't give
up!!!!
— Lori S.
July 23, 2008
You can try to fight the insurance company, but from my understanding if it
is excluded, you can't have the procedure. I personally got tired of
hearing that and I just had a GREAT experience in Costa Rica- lap RNY for
11,500. Plus, my husband and I got a second honeymoon out of the deal!
Beautiful place and you would be surprised at how many Americans are there
having dental work, bariatric surgery, etc. If you want to check it out the
website of the hospital I used is: www.hospitalclinicabiblica.com Best of
luck to you whatever you decide!
— darrelsplace
July 25, 2008
Most likely, the exclusion is a decision by your employer, not by the
insurance company. Unfortunately, I know from personal experience that
this is the situation most unlikely to change... you can fight when
insurance denies you, but when it's excluded from the get-go, you are in a
no-win situation. I would suggest speaking to your HR benefits coordinator
to find out the whys of the exclusion, then draft a comprehensive letter
and CC it to the bigwigs at your work; this is what I did. Include your
plea for them to include it on your policy and give as much personal info
as you are comfortable with, as well as research to back up your points.
My company listened and made efforts to look into including it, but in the
end decided not to due to cost and the relatively small number of employees
asking for it. I then appealed to my hospital's financial counselors and
worked out a sum far lower than regular out of pocket cost ($13,500 versus
$45,000). Then the surgeon and the anesthesiologist gave me breaks as
well. I was lucky enough to get a loan from a family member and was able
to place $5000 in a flexible spending account to make my first payment to
him. I am currently 9 days post-op. It was a long, tedious process, but
hopefully it's more than worth it! Good luck to you, you're not alone in
your quest!
— Melissa B.
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