Question:
My insurance is BC/BS of AL and has an exclusion.
I don't mind paying extra for a rider to be added, but is this going to make everyone that works there insurance go up, because if it does, I can't see the HR dept. being much help to me. Also one lady said that her BC/BS had an exclusion but her paid because of co-moridis, can you explain that? — rachelb34 (posted on January 20, 2008)
January 20, 2008
Most insurances still do not pay for weight loss surgery but if you have
high blood pressure, high cholesterol, edema, migraines, etc those are co
morbidities and if they are documented in your medical records as being a
result of your weight--your insurance will pay if you have the right
documentation.--Karen
— Karen M.
January 20, 2008
Insurance companies cover primarily RNY surgeries on two factors. One is a
BMI that is greater than 40. Second, if the BMI is less than 40, some
co-morbid conditions must exist. These include diabetes, hypertension,
elevated cholestorol counts under medication, sleep apnea, joint problems,
and possibly others. My BMI was 39.5, but I got surgery because I had sleep
apnea, and was taking blood pressure and cholestorol medictions. Not every
insurance company has the same qualifications0--some may say 2 co-morbid
conditions, others may state 4, etc.
— Dave Chambers
January 20, 2008
From speaking to my HR Reps, it not the insurance company that elects not
to cover the surgery, it's your employer. The employer is responsible for
paying the premiums and they can elect to pay for it or not. As another
posted stated, although there is an exclusion; the company will have to
cover if it having the surgery is "medically necessary."
If you think about it the MONEY ASPECT; insurance and pharmacy companies
don't want us to have the surgery because it keeps them in business and
keeps us buying medications for the various ailments we have to deal with
on a daily basis in order to make it from one day to the next. Oh I'm sure
the insurance companies don't TALK employers into covering the insurance;
but companies are starting to see that the successes of the surgery
decreases the number of sick days taken by a morbid obese employee. They
are starting to come around.
Also the states need to start coming around by enacting legislation that
will require a company to cover weight loss surgery. The State of Maryland
has such a law and the employer must employ at least 50 people. I think as
WLS becomes more and more successful; more states are going to implement
legislation (with our help) to make such coverage mandatory. I suggest
those who live in states that do no have such legislation write your local
representative to see what can be done to implement and pass such in your
state.
— the7thdean
January 20, 2008
I also have BC/BS. Mine also had an exclusion. They exclusion said that
my insurance would not pay for weight loss surgery, except in the case of
morbid obesity. It did not state any co-morbidities, only morbid obesity.
I was approved on my first submission. My doctor knew what the insurance
company was looking for, so all of our ducks were in a row. I was approved
within 4 days. Good luck!
— Debbi S.
January 21, 2008
I have blue cross blue shield and it has an exclusion and I was told no
because we are fully funded. Anyone else have that. I have an exclusion and
the refused and I also have medicaid and am waiting on that. Mine Antheim
of Mo.
— dawnspaints
January 21, 2008
I am very thankful for you asking this question because the answers you
have received have helped me as well. My insurance is through United
Healthcare and I also have an exclusion to WLS on my policy. I was under
the impression that if there is an exclusion, there is NO CHANCE of the
surgery being approved. Maybe there is a chance......Thanks again.
— Lisa L.
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