Question:
Serious Insurance Exlclusion. What do I do now?
I work at Walmart and have bc/bs PPO Blue. My employee hand book states," weight control and the treatment of obesity or morbid obesity, including gastric bypasses, and stapling procedures, even if the participant has other health conditions which might be helped by the reduction of weight"-BIG exclusion. I need this I'm 320 pds. and gaining. What should I do? — Brandi7920 (posted on March 25, 2003)
March 25, 2003
1) hire a lawyer. http://www.obesitylaw.com/ claims a 50 percent success
rate in overturning exclusions.
2) enlist the support of your employer to have the exclusion eliminated the
next time the insurance contract comes up for negotiation.
3) self pay.
4) get a job with insurance that covers WLS.
yes, i know the last two are options for very few people, including me.
Good luck.
— Kasey
March 25, 2003
Brandi,
Does your Walmart have any other options fos insurance other than the
Walmart/BCBS one? I know they are not available in all areas of the
country but, in Massachusetts Walmart also offers Tufts and Harvard Pilgram
HMO options which are a bit more expensive but also cover more in terms of
health expenses. I have contacted Tufts on two different occassions and
was told that there is no such weight loss surgery exclusion in their
contract with Walmart. I'm still in the approval stages though so who
knows what will happen then. But maybe it's worth looking into at open
enrollment time.
— AuntieT
March 25, 2003
I know this isn't the answer you want to hear but I've reached a point in
my life that I'd rather hear the bitter truth rather than have things sugar
coated - possibly you feel the same way. In the state of Alabama the
Wal-Mart exclusion is air tight. I am a Bariatric Surgery Program
Coordinator for a large hospital and also host a large open support group
for several hundred members. None of our folks have EVER beaten the
Wal-Mart exclusion and this includes folks who vigorously appealed and even
hired lawyers. I don't think it means you should give up. I just think it
means that more of us should lobby Wal-Mart to begin providing coverage for
this surgery. Heck, maybe we should boycott them. Let's face it - most of
us shop there and without our business they'd be in a pinch. Best wishes to
you!
— ronascott
March 25, 2003
It sounds like that if you want this surgery that you are either going to
have to change insurances (if multiple choices exist at your current
employer) or change jobs...JR
— John Rushton
March 26, 2003
That's a hard one. I have BCBS PPO of GA and had what I thought was an
airtight exclusion. I almost didn't pursue it any farther once I read it.
I have an individual policy and I guess it helped that I live in Ga. But
the insurance company told me that if I could prove it was medically
necessary they would have to approve me even with the exclusion. Thank God
they did had surgery 1/17/03. I suggest that you call your insurance
customer service and ask them even with an exclusion if you prove medically
necessary do you have a chance. Best wishes:)!!!
— Kimmie C.
March 31, 2003
Brandi,
Sorry to say I have been through this. You can read my profile. I
appealed and talked to Walter Lindstrom (Obesity Surgery Lawyer) He said
he has never been able to overturn a ruling from Wal-Mart. I had to wait
to change to UPMC insurance in Jan. I am now 3 weeks Post-Op. The
insurance is still through Wal-Mart but they don't go by the handbook. It
really is stupid. I am very sorry for you. I hope that you can get an
alternative insurance. Feel free to e-mail me. Susan Wagner
— Susan W.
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