EXCLUSION IN INSURANCE

ruckle
on 6/18/07 3:00 am - west babylon, NY
IS THERE ANYTHING I CAN DO IF THE INSURANCE COMPANY IS SAYING THAT THERE IS AN EXCLUSION FOR WLS AND MY DOCTOR SAYS IT IS MEDICAL NECESSARY. THANKS
Dreamy
on 6/18/07 6:10 am

I see this question all the time, so I'm going to give you some information as someone who has worked in the insurance industry. A lot of people have your problem...there is an actual exclusion written in their policy for weight loss surgery.  Most people become really upset with the insurance companies because of this, but they've got it backwards. The insurance companies would love to sell as much coverage as possible when they sell their policies. It's the company that you work for that is to blame. With health costs as high as they are in the U.S. and elsewhere, companies who offer health benefits to their employees are looking for any way that they can possibly cut costs. This is why they've started to bargain with insurance companies, to say, "okay, we want to buy your policy for our employees, but we're wondering if we can refuse to purchase coverage for certain procedures so that we can get the policy as a less expensive cost."  In this way, the benefits that your company has chosen to offer its employees includes medical coverage except for weight loss surgery. It usually means that your premiums are lower. Often, I see people on these boards spending all their energy and efforts, calling and writing their insurance companies with documentation about how desperately they need the surgery. In my opinion they are wasting their time. If you worked for a company that didn't offer any dental benefits, it wouldn't matter if you sent a thousand letters to dental insurance companies telling them that you desperately need a root canal. They would simply tell you that they are sorry, but you haven't purchased any coverage through them. It's also similar to people who buy insurance for their houses that excludes flooding. If they lose their house in a flood, their insurance isn't going to cover it. That being said, it infuriates me that there are so many companies out there who think they can offer medical benefits to their employees that exclude weight loss surgery. I mean, can you imagine if you worked for a company that said "we offer medical benefits, but it's cheaper if we buy policies that exclude treatment for breast cancer...so we exclude breast cancer treatment"??? People would be outraged. For some reason in this world, it's still politically correct to discriminate against obese people. I guess the advice that I would offer to all of you out there who have a policy with a weight loss surgery exclusion is this: do everything you can, but if the insurance company won't budge (and I suspect they won't), the place where you should be concentrating all you efforts is at your workplace. Write letters to your human resource representative (or whoever makes decisions about the benefits they offer) and demand that weight loss surgery be included in the available policies to sign up for.  Some companies offer their employees several choices of insurance companies and policies. Do your homework. Make sure you read the fine lines. Maybe one of the other available plans have weight loss surgery included. Wait until next year and sign up for that one. It might be a more expensive plan, but if you need the surgery, it would be worth it.  If every single plan that your work offers has an exclusion, demand to know why. Remember, the insurance company wants to sell as much insurance as they can. It's your workplace that doesn't want to buy weight loss surgery insurance. Write to them and demand to be treated fairly as someone with a medical condition who needs treatment when other treatments have failed.  Again, you're not alone. I've lurked the message boards here for a while, and I see this same question all the time. "What do I do if my policy has an exclusion?" And most of the time, I see others encouraging that you write to the insurance company explaining why you need this surgery. Like I said, my advice would be to write to your workplace instead of the insurance. I could be totally wrong, but I haven't heard of anyone successfully getting insurance to cover it when they had an exclusion. If anyone has, please post...I'd be interested to know. And if all else fails, I know that there are a lot of people on this website who have paid for surgery themselves. There's a message board on this site for people who have had their surgeries for really affordable prices in Mexico or Brazil or elsewhere (check the message boards for "south of the border"), where medical costs are more reasonable. When I first learned how many people do this, it kind of freaked me out. I imagined filthy basement clinics in Mexico. But the more I looked into it, the more I realized that it's not like that at all. There are many facilities "south of the border" that actually cater to Americans. Often the surgeon has been trained in the U.S., speaks fluent English, maybe even is a U.S. citizen; but chose to do business in Mexico because the costs are so much more reasonable--and they wanted to be able to get more business from all the people who don't have insurance coverage for weight loss surgery. They have top-notch facilities that are like high class resorts...and most of their patients are Americans. I've even heard that some of them are actually much cleaner and higher-rated hospitals than anything you can find in the U.S. Some people choose to have their surgery in another country because they are better than most U.S. hospitals in their city. It's always an option to consider. But do lots of research to make sure you're picking a good clean facility with a certified surgeon! Another option is to get a medical loan, and get the surgery here in the U.S. with the understanding that you'll probably be paying for it for a few years. It's not an impossible price for self-pay. Think about it...is it any more expensive than a new SUV? Not really. And I'd much rather have a new healthy body than a new SUV. People take out loans for brand new cars that they don't really need all the time. And most loans for medical reasons actually have more reasonable interest rates. Anyway, this is just my two cents. I'm just hoping to offer some hope for those of you out there with the dreaded EXCLUSION. Good luck, no matter what you decide!

ruckle
on 6/20/07 10:53 am - west babylon, NY
Thank you for info and advice
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