Update to 12/21 post re Self-Pay... any thoughts/

(copy of my recent post on the main board) My company"s 2006 insurance covered WLS with the common criteria. I am 4.5 months into my 6 month MD supervised diet. Nutrition counseling and psych testing has been done. Cardiology stuff is scheduled...  BUT - my company has now chosen an alternative policy from a different carrier for some employees in some states, including mine. This was all announced very late in 2006 so I'm thinking negotiations with the original insurance company broke down in terms of a few states, most likely based on cost. The alternative policy has a written exclusion for WLS and no rider added to cover it. The original policy continues to cover WLS for employees in "the right" states in 2007. I have contacted HR to request they consider:  1)  allowing me to stay on the original plan for 2007;  or  2)  purchasing a rider on the new policy to allow WLS with  criteria similar to the old policy. The VP in the main office is "looking into it." I am hopeful - but not counting on anything. There may even be a legal issue with providing different insurance coverage for different employees in the same company - but I sure don't want to play that card if I don't have to! I love my job and do not want to become embroiled in a contentious legal battle with the company. So-- that leaves me with the option to self-pay, possibly. I do not have the 24K it will take to do that, except in my 401K.     YIKES!!  I have decided that money will not be the reason I do not have surgery (I will have a lap RNY) because I figure that if I do not have surgery, I won't live to enjoy retirement anyway.  So if necessary, I will rob my 401K. I would love to hear from others who have had to self-pay - or have any other wisdom to share regarding my situation. Thanks in advance,

Hey Fiona, I replied with this comment just a few days ago, and maybe it may or may not help you, because your situation is nerve wracking and unfair.   I hope you don't mind just a tiny bit of advice that has helped me with some thorny issues.  It doesnt give you and answer but I feel it's good advice.  Maybe Paul or Gary can chime in with pragmatic answers but here goes...(I've cut and pasted).... I think Andrew Carnegie said it best when he stated: When faced with turmoil, 1. Imagine the worst case scenario 2. 'Decide ahead of time' what you will do in     case the worst thing actually happens. 3. Proceed calmly with step 2. Let's say then the insurance actually denies you after the whole 6 months. You have to ask yourself if you are up to fighting it. If indeed you are not up to it.  Next thing you need to do is ask yourself  another important question....are you up to a 'self pay' operation. Either you are or you aren't ... you have to decide to proceed , fight, or self pay. Or....this is a biggie,  not have the procedure at all. Keep us posted.

As I said, I have decided to have surgery one way or the other - even if I have to self-pay. The only thing I can imagine that would interfere with that plan is some sort of health problem that would contraindicate surgery. Some have suggested  I consider going out of the country for surgery but in the long run - even though I would support others who do go south of the border - I don't think I would be comfortable doing that. The place I have chosen is designated as a Bariatric Center of Excellence by the ASBS.  Also, I worked in the OR with one of the surgeons years ago when he was a brand new baby doctor. He is very skilled. As you can tell by now, I like to control as many variables as I can.   I wonder about complications after self -pay, which are usually not covered by insurance. That can end up costing a lot of money. It doesn't take long to exceed 100K with complications, like infection. Please keep contributing your thoughts and experience to this thread.  I would love hearing from others on this topic. It is comforting to know I am not the only one dealing with this! Thanks again!

I would like to say this... Take the money out of the 401K if that is the option you are left with and be thankful that avenue is available to you. With the extra energy you will have because of the WLS you will definitely feel that it is worth it. I am still pre-op, and I have insurance that should not be any problem getting approved with- However,  my Aunt's insurance completely excludes weight loss surgery and she is considering maxing out credit cards or doing whatever she can to get the surgery financed...She is miserable living the way she is- as most of us are and I totally agree that I would do whatever possible to get it done.   Good luc****rtainly hope that the insurance works out instead of having to take money out of the 401K. Jenifer

Thanks, Jenifer. You are right - I am lucky to have other options to finance the surgery if I have to. My lingering concern is the cost of complications which would undoubtedly not be covered. Medical bills can financially ruin a person, not to mention the effects of complications on your health. Like so many issues in real life - the answers are not cut-and-dried. Also, there are no guarantees, which is always a big bummer to a control freak like me. (  ) Gratefully yours,

Fiona, Are you SURE that if there are complications from your WLS, that insurance won't cover it???? I think I am of the opinion that they will.  And this is why.... Say you have lets say...a leakage, and the Doc has to go in there again.. Well now it is not WLS,   it is coded as something else...perhaps emergency surgery for  internal whatever..... My point is the 2nd surgery is considered something else,  not WLS...right?? Call insurance and check it out to be on the safe side..   In fact instead of that, first send a message to Gary on this site, he's a lawyer, who handles just this type of thing. I think if I were you, being self pay, I would stay in this country too, because it's more likely to give you peace of mind with the unstablility of your insurance company. I am proud of you for being so brave.   You keep on keeping on. Your friend

Any complications linked to an excluded surgery are are almost always not covered. When I spoke with my surgeon's office, they said that the surgeon would likely not charge for uncovered treatment related to complications - and the hospital and other providers usually work with people on a reasonable payment plan.  But still - it can be a LOT of money. In the end, I keep coming back to the same place - this surgery feels like the best option for me. I can't imagine allowing money worries to keep me from doing the best thing. If at all possible, I would do anything to save the people I love (my kids, friends, etc.) from pain, sickness or harm without thinking twice about my bank account. With several co-morbidities that are fairly stable for the moment, I know I am a walking time bomb healthwise. And once you hit the tipping point, there is no going back from permanent damage from chronic conditions related to obesity - no matter how much weight you lose. I am really just trying to get my head ready for the possibility I may have to self-pay. I still don't know definitively. I also hope that I get to skip the complication experience, too. I just want to make sure I consider all factors I possibly can.