Hit a large roadblock...

So I finally got a straight answer from my insurance company about my coverage. Not covered. It's excluded entirely from my plan, medically necessary or not. Apparently the last guy I spoke with when I called and gave my information just didn't know WTF he was talking about and gave me false information and false hope. I'm now faced with only two options.. #1 Pay for it entirely myself #2 Wait until September when my company has open enrollment in benefits and switch to a new plan. I'm not sure this is even really an option though, as the other plans likely exclude the surgery as well. My spirit has really been crushed.. I've been working very hard to pay down my current debts (credit card, student loans..) but if I have to fund this surgery myself, I will have to either charge it or get a loan. I thought my mom would probably be against before, but I know she will now that the money is all on me. She has nagged my sister and me our entire lives not to get in too much debt 'or we'll end up like one of the ****ty loan applications she sees everyday at work - up to their neck in debt and can't get a loan for a house' This leaves me with a few questions... 1- If my insurance company won't fund the surgery, will they not fund anything related to it either - such as pain meds and other misc fees? 2 - Just how much cost is involved? When I initially contacted my surgeon for a consult appt (still waiting on his office to call me...) I was told about the consultation fee and the surgeon's fee. (which was 212+5500) but I know there's more than that. (Hospital stay, anesthesiologist fee.. ?) and labs and follow ups afterwards... 3 - Who typically gives a better interest rate - credit card or loan? I could just cry.. but I can't because I have to go back to work now. >_<; Thank you for reading and for your support.

You do have more options - you can still submit and when they deny appeal - sometimes you can get it covered in appeal... depends on your appeals process and *****views the appeals. Sometimes the company the insurance is thru (the employer) has final say on approvals. Another option would be to go the legal route and contact a lawyer - there are ads for them here on OH... many people have had success that way and its (typically) much cheaper than paying for the surgery OOP. Another option is to speak to your HR about having WLS covered on one of the plans they offer or find out if any of the plans already cover WLS. As for your other questions 1 - if they exclude the surgery they typically exclude post-WLS follow up care as well as skin removal etc. They wouldnt cover anything relating to the surgery pre or post-op. Some of the visits your surgeon could code in a way they would pay, but the majority of everything would come OOP. My previous insurance covered WLS, my current doesnt - anything WLS related I have to pay OOP. I get around this by having my lab work done as part of my physical with my PCP and a copy of the results sent to the surgeon to review etc. 2 - depends on what the surgeon requires in the way of vists, pre-op testing and hospital stay... also what surgery - if you are looking at RNY I think most people run around 20,000$ 3 - depends on your credit score - its all based on credit rating... more than likely you would have to go with a loan because most credit cards dont give you a 20,000 limit ya know? Either way you are looking at a 18-30% interest rate in most cases.

Thank you, Jennifer. I never even thought about a lawyer... I'm hoping a lot of my questions will be answered when I have my consultation, I'm just anxious to get answers to relieve my mind and waiting forever to schedule the consultation doesn't help! I'm the type that tends not to rely on others to get things done, so having to wait on my surgeon's office to call me to schedule is grating on my nerves >.<; UPDATE: The following exerpts come directly from the health benefits guide on my employer's website for my health insurance plan.

Services, Supplies, and Medical Expenses Not Covered

Certain services and supplies – and certain medical expenses – are not eligible for benefits under your Traditional Health Coverage. The following is a list of services that are not covered under your Traditional Health Coverage:

· For charges made for care or treatment which is not medically necessary;

· Weight reduction surgeries (such as, but not limited to, gastric placation)

These examples are not intended to be all-inclusive. Charges for other procedures, services or supplies may be excluded if it is determined that they are not medically necessary, reasonable or covered by your Traditional Health Coverage. The Plan sponsor continues to reserve its discretion to exclude charges for any other condition, disease, ailment or illness which are not deemed to be medically necessary, reasonable or otherwise covered. Thus, no inference should be drawn from the inclusion or exclusion of any specific condition, disease, ailment or illness, or its related treatment, diagnosis or care, in this section or otherwise. So does that mean that even though it states it's excluded, it may not actually be excluded if it's deemed medically necessary.. ? Damn.. these insurance companies really know how to weed out the determined obese people from the undetermined.. make us jump through so many loops!!

That means its covered if you can prove medical necessity. WLS surgery is always under 'not covered'.... the magic words are 'unless medically necessary'... in your case they chose to word it a little differently - I would call the insurance back and ask for their WLS guidelines. I will say yours is worded much more difficult than most - they really make it still a question on if its covered or not - either way I would submit!!! I use to work at a major insurance carrier - many times this benefit is misquoted by customer service because at first glance its 'not covered' since its under the not covered section - they have to look and read the entire benefit to really see if its covered or not.