Complications and ins

1.  She self paid because her insurance did not cover the surgery or complications of the surgery

2.  She had a complication of the surgery

Does insurance now cover complications of a surgery that is specifically excluded?

I had insurance that specifically excluded weight loss surgery.  I was told that if I self paid then I needed to have enough resources to self pay for any complications.

Ok so your insurance told you, if your stomach ruptured, and you were bleeding internally on your death bed, they wouldn't cover that?  Maybe it varies by state...hmmm... and yes you are right about what she said, as I said in my response, i misread her original post.  

My knowledge is yes, if you have a life threatening complication, insurance would cover it.  I wonder if it varies state to state.  For example. if your stomach ruptured, and you were bleeding internally, your insurance should cover the emergency services provided (including surgery if you are admitted). That's my understanding.  

A lot of times, the people who pick up the phone for the insurance company don't know ANYTHING about claims processing.  I guess I'll have to research this more to let you know for sure.   

I found many examples like the response below.  But I would have to really research and get back to you:

 Although insurance companies say they will not cover complications of cosmetic surgery that is not completely true. If you have a sudden allergic reaction to a medication, even if that medication is given during cosmetic surgery, that is lifethreatening you can bet insurance will cover it. Although these events are quite rare it is not a good idea to undergo any cosmetic surgery without having basic health insurance for these rare events. That is what insurance is for - protection against/for rare events. One of my patients took large amounts of aspirin before surgery without telling me and despite my numerous instructions before hand not to do so. His blood pressure dropped during surgery and I admitted him to the hospital for a few days. After some back and forth his health insurance covered the admission because it was for a life threatening drop in blood pressure.

Several years ago a virus attacked my body and left me with zero hearing in one ear.  I had a series of four cortisone shots directly into the ear.  The cost was $1,800 per shot.  I went ahead with the treatment before timing was important and dealt with the cost later.

Insurance did not pay a penny because the treatments were done in the doctors office instead of in a hospital.  So I negotiated with the ear doctor and then made payments to him.

I would not jeopardize my health or the health of a family member because of money. 

My husband needed a kidney removed.  The hospital covered by my policy did not do the procedure laparoscopically.  The hospital up the street from that hospital did.  I chose the  first hospital and the insurance ended up paying for it.  But I made that decision with full knowledge that it could be denied.

If I were bleeding to death from a ruptured stomach and insurance did not cover it, I would still want treatment and then figure out how to pay for the treatment later.

The original poster's best move now is to appeal and let the hospital know that the claim is being appealed.  But also to be prepared to negotiate with the hospital for reduction in fees and a payment plan if the appeal is denied.

I agree with you 100% if you need a procedure get it done regardless of insurance coverage.  Why would insurance deny a procedure if it was done laproscopically? That blows.  I guess there are a lot of weird policies and rules out there that i wasnt aware of. You would think insurance would prefer treatment within the doctors office so it would be less expensive

I'm afraid there's a lot you don't know about insurance companies. My revision was precertified by the insurance company. One month after my surgery I get a bill for $53,000 from the hospital. The insurance company says a precertification is not a guarantee of payment. They denied my surgery after the fact. I ended up making a cash payment deal with the hospital. Now, any complications will be my responsibility. Please stop telling people that that insurance will pay for everything because they don't. 

I never told anyone "insurance will pay for everything".  Your example does not in anyway refer to my comment, where I said if you enter the ER On an emergency basis, and later I qualified and said if the surgery is determined to be the appropriate action, insurance should pay for it (I believe I said should) later after multiple people told me of their personal experiences, I recanted.  My personal experiences as an examiner, my personal experiences with doctors, hospitals, and insurance was the basis for my comment.  I am not sure why everyone is up in arms about my two sentence comment.  It's not like I was her claims examiner and told her incorrect information which led to her having an unapproved surgery and costing her $100,000.00.  If you don't agree, that's your right.  I have no idea the specifics on your claim and why it ended up being denied.  But chances are if you had fought them, they would have lost.  But at any rate, as I've now stated at least 6 times, I have learned from people's personal experiences, that my personal experiences do not match many other insurance carriers (possibly in other states) and their policies.  I was not aware there were bizarre policies out there who are in the habit of denying surgeries left and right.  Our TPA believes and so do I that our job is to provide the care and medical attention needed for an injured worker to return to work.  We are not the adversary of the injured worker, and instead we really want them to get better.  Obviously private insurance carriers do not share in that mindset.  I appreciate your comments and have learned due to this post the vast difference in policies out there.  

Here's MY story.  I had VBG surgery in 1986. It was self pay.  My surgeon mutilated me and then disappeared off the face of the earth.  I had 25 years of complication after complication and not one doctor would help me.  They kept prescribing medication that never helped.  Jump ahead to 2008.  I had GERD so bad that the flap that prevents the stomach contents from coming into my esophagus had completely eroded.  I would wake up with stomach content on my pillow every morning.  I had acid sores the size of dimes in my mouth and all of my teeth were loose from stomach acid constantly in my mouth.  I had 6 tumors removed from my esophagus ( pre-cancerous, one of which we are currently monitoring).  I was in excruciating pain. My doctor had me on 160 mg Prilocec  (normal dose is 20mg) with no relief.

I went to six doctors who told me they had never seen anything like this and would not touch me. Finally I was referred to Mayo Clinic and the top gastric surgeon said that he thought he could repair the damage done to me by my first surgeon.  He also told me that if I did nothing I would end up with esophageal cancer. 

I called my insurance and was told that they would not cover the surgery that would save my life because it was related to a WLS and they do not cover any WLS in my plan.  I had to fight with them for an entire year... all the while...  I was in severe pain.  They denied me 4 times.  I just kept on fighting and finally they approved my surgery.  

So your advise that if you go to the ER ... and if you are in pain... and you request to be admitted ....your insurance will pay for it is PURE BULL CRAP!  

My advise to the OP... Just keep fighting.  I had to get doctors records from years back to prove that I had done everything possible to correct my complication and it was steadily getting worse..  The insurance company kept telling me that the surgery they were suggesting at Mayo was "experimental" and therefore they wouldn't pay for it.  I had to prove to them that it was my last option before they finally relented and paid up.

Honestly, i don't know the basis of them denying your surgery.  Unless they had sent your request to UR and it was denied.  A claims examiner is not allowed to just say that your GERD is related to your weight loss surgery at all.  At any rate, I admitted earlier, that there is a lot about insurance I had no idea about.  My personal experience as an examiner, and my personal experience with insurance, and my own surgeries did not shed this kind of light.  I am really happy you all brought these different scenarios to my attention.  As you stated, in the end your insurance covered it even though they stated it would be denied, so they are just being jerks.  Not making a legally sound argument.  I'm so sorry about the pain and trauma you experienced!  That is god awful and I'm glad you kept fighting.  If we have an accepted claim, we immediately send surgery requests for medical necessity.  If the surgery is required, it's approved.  I'm sorry if my insurance knowledge is a lot differnet than everyone's experiences.  I really am happy this was all brought to my attention cuz like I said I had no idea an insurance company could be so cruel!  

Yeah they can be because in the end they are a business out to make profit. I see some points like the fact people do scam and cost them a lot of money but in the end it bothers me that put the all mighty dollar over lives. I jus****ched a documentary called Hot coffee for my business law class. It was eye opening on what big business is doing in the legal system.