Help! insurance won't pay

The whole pre-existing thing varies state by state, too....I had my surgery on a PPO and then switched to Medicare, and Medicare has even  paid for a lot of the complications.....and generally medicare is pretty low bottom insurance....but my understanding is that overall, complications should be generally covered  for  treatments that are deemed medically necessary, if a person had creditable coverage or, in other words had insurance of some kind, for 6 months prior to  when a complication occurs. Not always, but it's worth checking on the laws n your state and your employers policy. Some of my former coworkers went and had medical things done out of the country and later had things medically necessary complications covered by employee insurance. It gets very tricky, so check with your insurance company, your state, and your employer.

I had the same issue with my employer.  I went online and paid for personal insurance that did cover it.  I noticed it was cheaper than the premium my employer pays so I asked them to pay for my personal insurance instead and they did!  I was shocked when I was approved by insurance less than 1 month after I joined.  But it all worked out.

First of all, I feel you! I have a lap-band (5 years ago, paid my insurance back then) and NO insurance plan I can get right now will cover anything related to it or any complications or even emergencies arising from it, despite it being a pre-existing condition because the plan language specifically EXCLUDES it. If that is the case there is nothing you can do.

Here are some suggestions though:

1. See if your plan has a cost containment clause. Sometimes things that would not otherwise be approved can be made exceptions for if you can prove that the cost of covering it is way less than the cost of not covering it. I.e. how many health issues do you currently get treatment for that are likely to resolve after major weight loss? Or which health conditions can you nearly certainly prevent by getting the surgery? 

2. Can you leave your employer plan and go to the exchange? You won't qualify for subsidies if you turn down your employer's offer of coverage but if you live in one of the great states that mandates WLS to be covered on the exchange, you are in luck. Exchange open enrollment starts 11/15 so you can join and leave your company's plan (but check with your HR department).

3. See if your employer would be willing to help you self-pay by giving you a cash bonus. This will only work if you are a highly valuable employee that they don't want to lose. 

I am currently in the process of getting my employer to creatively finance a VSG revision (from band) even though our health plan specifically excludes WLS or weight loss treatment of any type and I live in a state where the exchange or individual plans aren't required to cover it, so I'm basically screwed. But getting creative...

Do you have any co-morbids that would qualify you  for WLS?  If so, than you doctor should be able to submit a letter to your insurance company on your behalf to get them to approve it.

this is incorrect information. If her employer has not BOUGHT coverage from the. Insurance company,it doesn't matter how many co morbidities she has or how many letters her pcp writes,  insurance isn't going to pay for anyone to have a procedure the employer hasn't bought coverage for. 

Is the exclusion (under no cir****tances or only "if deemed medically necessary") read your policy and look for loopholes like that. "Deemed medically necessary" may just require additional comorbidity documents. 

If there is a way to get it approved Walt Lindstrom could find it (worked with him on the OAC board, awesome guy, post-WLSer too) www.wlsappeals.com 

Best wishes. I was a self pay in Mexico (not a choice for everyone but was a great one for me.)

~Michelle "Shelly"

Yes, I experienced this too.  I have an employer that excludes any benefits for weight loss surgery from their health plans.  Of course it doesn't make sense since in the long run it's probably cheaper than the costs of the chronic illnesses the extra weight brings us all.  It is what it is and when it happens you are trapped if you have no other resources and it makes you angry to be trapped.  I appealed to my employer with the $250,000 they had paid in the prior two years for health claims for hospitalizations, doctors and and testing,  and they still refused.  It took me 7 years, but I was finally able to get enough money in my 401K retirement account that I could borrow enough from it to fund my own surgery just a month ago.  I hope you too can find a way to continue your journey.

Actually, it isn't cheaper until about 5 years out (and many people don't stay on one plan that long, so that is why adding WLS coverage raises premiums so much).  Studies show that people who have WLS use MORE medical resources the first 2-3 years, but use less by 5 years out.

Lora

statistics also show that the average worker stays in the same job for two years before switching. Insurance companies are hoping they will not have to pay out much on each individual,often stalling as long as they can to try to wait out the two eyes before that person leaves for a new job and they are off their books.