Seeking insurance clarification

Lana Bonk
on 3/11/07 1:02 pm
I'm scheduled to attend an information seminar in April and I'm currently going through the preliminary paperwork process.  I pulled my insurance benefits book to see what it says about surgery and don't understand some of it.  Below is what my insurance benefit says.  I have a BMI of 42, but other than back pain, nothing I would consider another condition aggravated by obesity...  Other than the first paragraph, I'm curious about (b).  Are they just wanting a record of my weight for 5 years?  This is First Health insurance.

Charges for weight reduction except for the medically necessary treatment of morbid obesity (a body weight that is 100% over the weight given in standard tables); endogenous obesity (caused within the body) including but not limited to metabolic factors such as hyperinsular, hyperinterrenal, hypogonad, hypothyroidism, hypercholesterolemia, and obesity due to hypothalamic lesions; or exogenous obesity (caused by overeating) if: a diagnosis or morbid obesity is given and a separate medical condition is present which is aggravated by obesity (e.g. high blood pressure, chronic back conditions, varicose veins, etc.). For surgical treatment of morbid obesity you or your covered family member must be: a. twice your ideal weight; b. demonstrate inability to control weight through diet over a minimum of a five year period documented by physician's medical records, and must suffer from a documented separate condition which is aggravated by obesity, (e.g. severe diabetes mellitus, hypertension, alveolar hyperventilation, a chronic back condition, varicose veins, etc.). This must be documented by objective evidence provided by the treating physician; and c. you or your family member must be psychiatrically stable as documented by a recent psychiatric evaluation. Thanks a lot for your help!!!

(deactivated member)
on 3/12/07 1:37 am
Lana Bonk
on 3/12/07 2:30 am

Thank you so much for the reply!  Do you think "b" is saying that I have to have a co-morbidiity in conjunction with a high BMI?  My BMI is 42, however, I don't really think I have anything really caused by being overweight...  For the most part, my blood pressure is fine (I've never had to have it treated).  Surprisingly my cholesterol is good, no sleep apnea.  I do go to the chiropractor for back pain....

I talked to insurance this morning, but still rather confused.  I'm just hoping on BMI alone I would qualify.

Thanks again for just great information!

Jalana

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